Pulmonary Rehabilitation in Chest Diseases PDF

PULMONARY REHABILITATION For Obstructive and Restrictive lung diseases BY: DR.EMAN RASHAD Lecturer at Horus University In EGYPT (PHD, M.SC, CMTP, CSMT, CMP, KMCT, CLT ) RESTRICTIVE LUNG DISEASES Problems list : 1) Decrease inspiratory capacity (patien...

PULMONARY REHABILITATION For Obstructive and Restrictive lung diseases BY: DR.EMAN RASHAD Lecturer at Horus University In EGYPT (PHD, M.SC, CMTP, CSMT, CMP, KMCT, CLT ) RESTRICTIVE LUNG DISEASES Problems list : 1) Decrease inspiratory capacity (patient can’t do inflation of lung or lobes affected) 2) Decrease exercise tolerance 3) Pneumonia patients as suppurative and restrictive lung disease have also secretions 1+2 the main problems in all restrictive lung diseases How to deal with restrictive lung disease patients or how to solve these problems list? 1) Increase inspiratory capacity or improve inflation of lung or affected lobes by : Diaphragmatic breathing Segmental breathing (apical , lateral costal ,posterior basal) Exercises connected with breathing (exercises to moblize chest) Assistive devices : incentive spirometer Inspiratory muscle trainer 2) increase exercise tolerance :  the patient should be mobilized and start walking short distances which are progressively increased in length  Breathing control is taught to the patient in shorter and long walk in even surface and in stair climbing..(walking on treadmill , stationary bike, stretch exercises and light weight training ) The intensity of the exercise pograme increased with patient improvement to improve the exercise tolerance of the patient. Exercise testing is done for the patient to determine the intensity of exercise appropriate to each patient  RESTRICTIVE LUNG DISEASES Pneumonia Pleurisy Pleural effusion Pneumothorax Acute respiratory distress syndrome (ARDS) Fibrosing alveolitis  PNEUMONIA Definition Acute inflammation of the lung tissue Classification of pneumonia Anatomical – lobar, broncho, segmental Based on organism- bacterial, viral, fungal, protozoal, atypical Based on acquired infection – hospital acquired pneumonia, community acquired pneumonia, pneumonia in immunocompromised patients. Clinical features: Cough Sputum Dyspnea Chest pain – pleuritic pain Wheeze Crepitation's Fever Malaise Rigor  PHYSIOTHERAPY IN PNEUMONIA Aim: To reduce bronchospasm and to clear lung fields of secretions To gain full expansion of lungs To regain exercise tolerance and fitness Clearing lung fields Humidification may be necessary to moisten secretions. The method will vary according to the severity of the illness and may be by steam inhalation, nebuliser or IPPB. percussion,shaking,vibration and breathing exercises may all be necessary in a postural drainage position appropriate to the area of the lung affected. Sometimes suction is required for the very ill patient who cannot cough or expectorate. If there is an underlying bronchospasm then a bronchodilator may be given Clear lung fields of secretions in cases of ( pneumonia ) : In this case lung have secretions and also can’t infilat well due to problem in alveoli (contains fluid) (Suppurative and restricted lung disease) 1) Postural drainage to moblise secretions from distal to proximal 2) Cough or huff techniques to get rid of secretions from proximal to out Sometimes suction is required for the very ill patient who cannot cough or expectorate 3) Humidifications before postural drainage and cough Re-expansion of the lungs Positioning should be used to increase ventilation to the affected area Diaphragmatic and Segmental breathing (apical , lateral costal ,posterior basal) Incentive spirometer Exercise tolerance and fitness As soon as possible, the patient should be mobilised and start walking short distances which are progressively increased in length  PLEURISY Definition Pleurisy is a process whereby inflammation occurs on the visceral and parietal pleura which come into direct contact with each other to cause pain. Clinical features Pleuritic pain Pleural rub Cough Tachycardia and pyrexia may be present  PHYSIOTHERAPY IN PLEURISY Physiotherapy is usually inappropriate in the early stages. During the recovery stage, however, the aims are: To regain full thoracic expansion To minimise adhesion formation between the pleural layers To mobilise the thorax  Thoracic expansion is regained by teaching the patient localised segmental expansion exercises with manual resistance over the affected area both to guide rib movement and relieve pain. General deep breathing exercises and chest mobility exercises, such as sitting with trunk bending side to side, are important to regain mobility of the thorax and thoracic spine. Clinical features Breathlessness. The pressure of fluid reduces lung expansion. Cyanosis. This may be present in a large effusion. Pyrexia. This is usually associated with infection. Lethargy. The person complains of a lack of energy Pain. The person complains of pain. Definition PLEURAL EFFUSION Pleural effusion is an excessive accumulation of fluid in the pleural cavity Aetiology Pleural effusion is often secondary to conditions such as: Malignancy of the lungs or bronchi Pneumonia Tuberculosis Pulmonary infarction Bronchiectasis Lung abscess Blockage of lymph vessels Rupture of blood vessels Left ventricular failure.  PHYSIOTHERAPY IN PLEURAL EFFUSION The Aims Of Physiotherapy Are: To Prevent The Formation Of Disabling Adhesions Between The Two Layers Of Pleura To Obtain Full Expansion Of The Affected Lung To Increase Ventilation Of The Lungs To Increase Exercise Tolerance Following Immobility. Means: Breathing exercise to improve localized expansion and ventilation of the lung, later stage the patient is mobilized to improve the exercise tolerance.  EMPYEMA Definition Empyema is a collection of pus in the pleural cavity Aetiology condition of empyema usually arises secondary to pre-existing lung disease, such as bacterial pneumonia, tuberculosis, lung abscess, or bronchiectasis It may also occur due to stab wound or thoracic incision as a complication Clinical features Pyrexia Lassitude and loss of weight Tachycardia Dyspnoea Pleuritic pain severe at first then decreasing in Severity Diminished thoracic movements  PHYSIOTHERAPY IN EMPYEMA Aims To minimize adhesions formation within the pleura To regain full lung expansion To clear the lung fields (empyema with bronchopleural fistula) To maintain thoracic mobility To improve exercise tolerance Means Breathing exercise to improve the ventilation as well as expansion of the lung Postural drainage to remove the lung secretions in different positions based on the auscultation findings (empyema with bronchopleural fistula) Coughing encouraged with support of the drain tube Gradual arm and trunk exercise incorporated to improve the thoracic mobility Breathing control is taught to the patient in shorter and long walk in even surface and in stair climbing..(walking on treadmill stationary bike stretch exercises and light weight training ) The intensity of the exercise pograme increased to improve the exercise tolerance of the patient. PHYSIOTHERAPY MANAGEMENT FOR OBSTRUCTIVE LUNG DISEASES COPD  The common disease entity of chronic bronchitis and emphysema is known as COPD (chronic obstructive pulmonary disease), COAD (chronic obstructive airways disease), COLD (chronic obstructive lung disease), CAO (chronic airflow obstruction) or CAL (chronic airflow limitation).  Problems list : 1) Secretions in airways 2) Problem in expiration (cant deflate lung well) 3) Episode of dyspnea 4) Use accessory muscles and increase work of breathing 5) Decrease exercise tolerance How to deal with obstructive lung disease patients or how to solve these problems list? 1) Clear lung fields of secretions :  Postural drainage to moblize secretions from distal to proximal with percussion ,vibration ,shaking  Cough or huff techniques to get rid of secretions from proximal to out Sometimes suction is required for the very ill patient who cannot cough or expectorate  Humidifications before postural drainage and cough  Diaphragmatic breathing as use it in cough and postural drainage  Assistive devices: 1) PEP ( Positive expiratory pressure breathing ) 2) Flutter device (oscillatory PEP) 3) Vest ( high frequency chest wall oscillation)  2) problem in expiration : Controlled pursed lip breathing  3) relieving episodes of dyspnea: Teach him how to deal with through leaning forward using Controlled pursed lip breathing Learn him about pacing activities (tasks within the limits of patient ventilatory capacity) to prevent it  4) increase exercise tolerance: aerobic and strengthening exercise in the long-term management of airflow limitation to optimize oxygen transport in patients with compromised oxygen delivery is well established (20-30 min moderate exercise for three to four days a week) Moderate intensity interval training (MIIT) 4 sets of 4min intervals (55-75% max Hr) and rest (42 min containing warming up and cooling down) Exercise testing is done for the patient to determine the intensity of exercise appropriate to each patient  5) decrease Using accessory muscles and so decrease work of breathing :  Diaphragmatic breathing  Assistive devices : Respiratory muscle trainer  PRINCIPLES OF PHYSICAL THERAPY MANAGEMENT FOR COPD The goals for long-term management of the patient with COPD include the following: Maximize the patient's quality of life, general health, and well-being and hence physiological reserve capacity Educate about COPD, self-management, smoking reduction and cessation, medications, nutrition, weight control, other lifestyle factors, infection control, and the role of a rehabilitation program  Facilitate mucociliary transport Optimize secretion clearance Optimize alveolar ventilation Optimize lung volumes and capacities and flow rates Optimize ventilation and perfusion matching and gas exchange Reduce the work of breathing Reduce the work of the heart  Maximize aerobic capacity and efficiency of oxygen transport Optimize physical endurance and exercise capacity Optimize general muscle strength and thereby peripheral oxygen extraction Optimize respiratory muscle strength and endurance and overall respiratory muscle efficiency  Patient education focuses on teaching about the severity of COPD, self-management of the disease, the effect of smoking and smoking cessation. nutrition, weight control, hydration, relaxation, sleep and rest, stress management, activity pacing, energy conservation, and infection prevention (e.g., cold and flu prevention, flu shots, aerobic exercise, diet, sleep, and stress management).  The primary interventions for maximizing cardiopulmonary function and oxygen transport in patients with COPD include some combination of education, aerobic exercise, strengthening exercise, ventilatory muscle training (strength and endurance), low flow oxygen, mechanical ventilatory support for home use, chest wall mobility exercises, range of motion exercises, body positioning, breathing control and coughing maneuvers, airwayclearance techniques, relaxation, activity pacing, and energy conservation. An ergonomic assessment of work and home environments may be indicated to minimize oxygen demands in these settings.  The benefits of aerobic and strengthening exercise in the long-term management of airflow limitation to optimize oxygen transport in patients with compromised oxygen delivery is well established (20-30 min moderate exercise for three to four days a week) Moderate intensity interval training (MIIT) 4 sets of 4min intervals (55-75% max Hr) and rest (42 min containing warming up and cooling down) Exercise intensity is prescribed based on rating of breathlessness (modified Borg scale), in conjunction with objective and other subjective responses from the exercise test.  Patients with chronic airflow limitation alter their breathing patterns so that they tend to breathe with prolonged expiratory phases to maximize gas transfer and mixing in the lungs to minimize the effects of altered ventilatory time constants. To facilitate such a breathing pattern, the patient tends to breathe through pursed lips, which may create back pressure to maintain the patency of the airways