20-3-2023

CARDIOPULMONARY REHABILATION
LEARNING OBJECTIVES

In this Lecture students will learn:

 What educational content needs to be addressed

in a pulmonary rehabilitation program.

 How to properly integrate exercise into a

rehabilitation program.
DEFINITIONS AND GOALS
 The Council on Rehabilitation defines rehabilitation as “the
restoration of the individual to the fullest medical, mental,
emotional, social, and vocational potential of which he or
she is capable.”
 Pulmonary rehabilitation is the “art of medical practice
wherein an individually tailored, multidisciplinary program is
formulated, which through accurate diagnosis, therapy,
emotional support and education stabilizes or reverses both the
physio- and psychopathology of pulmonary diseases and
attempts to return the patient to the highest possible functional
capacity allowed by his or her pulmonary handicap and overall
life situation.”
CONT:
 The general goals of pulmonary rehabilitation are
to control and alleviate symptoms, restore
functional capabilities as much as possible, and
improve quality of life.
 The overall goal is to maximize functional ability
and to minimize the impact the disability has on
the individual, the family, and the community.
HISTORICAL PERSPECTIVE
 In 1952, Barach and colleagues recommended reconditioning
programs for patients with chronic lung disease to help improve
their ability to walk without dyspnea.
 In 1962, Pierce and associates published results confirming
Barach’s insight into the value of reconditioning.
 Christie’s work in 1968, other investigators have continued to
research the benefits of pulmonary rehabilitation.
 In fall 2006, the American College of Chest Physicians (ACCP)
and the American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) released their evidence-based
guidelines relating to pulmonary rehabilitation aimed at improving
the way pulmonary rehabilitation programs are designed,
implemented, and evaluated through patient outcomes.
CONTENT
 Group size, available equipment, and group
interaction will dictate session length.
 Patients should arrive 10 to 15 minutes before a
scheduled session in order to allow for informal
group interaction and support.
SCIENTIFIC BASIS
 Rehabilitation must focus on the patient as a whole and not
solely on the underlying disease. For this reason, effective
pulmonary rehabilitation programs combine knowledge from
both the clinical and the social sciences.
 Knowledge from the clinical sciences can help quantify the
degree of physiologic impairment and establish outcome
expectations for reconditioning.
 Application of the social sciences is helpful in determining the
psychological, social, and vocational impact of the disability
on the patient and family and in establishing ways to improve
the patient’s quality of life.
PHYSICAL RECONDITIONING
 Physical activity, such as aerobic exercises,
increases energy demands. To maintain
homeostasis during exercise, the
cardiorespiratory system must keep pace.
 Ventilation and circulation increase to supply
tissues and cells with additional O2 and to
eliminate the higher levels of CO2 produced by
metabolism.
BOX 55-1 BENEFITS FROM EXERCISE
RECONDITIONING

 ACCEPTED BENEFITS  POTENTIAL BENEFITS

 Increased sense of well-being
 Increased physical endurance  Improved secretion clearance
 Increased maximum O2  Increased hypoxic drive
consumption  Improved cardiac function
 Increased activity levels with:  UNPROVEN BENEFITS
 Decreased ventilation
 Prolonged survival
 Improved pulmonary function test
 Decreased heart rate results
 Increased ventilatory  Decreased pulmonary artery pressure
threshold  Improved blood gases
 Improved blood lipids
 Change in muscle O2 extraction
 Change in step desaturation
 Data from references 15 and 16
PHYSICAL RECONDITIONING
 O2 consumption and CO2 production also increase in linear
fashion as exercise intensity increases. If the body cannot deliver
sufficient O2 to meet the demands of energy metabolism, blood
lactate levels increase above normal.
 In exercise physiology, this point is called the onset of blood
lactate accumulation (OBLA).
 As this excess lactic acid is buffered, CO2 levels increase and the
stimulus to breathe increases. The result is an abrupt upswing in
both CO2 and VE (referred to as the ventilatory threshold).
 Beyond this point, metabolism becomes anaerobic, the efficiency
of energy production decreases, lactic acid accumulates and
fatigue sets in.
PHYSICAL RECONDITIONING
 Pulmonary rehabilitation must include efforts to
recondition patients physically and increase their
exercise tolerance.
 Reconditioning involves strengthening essential
muscle groups, improving overall O2 utilization
and enhancing the body’s cardiovascular
response to physical activity as noted in Box 55-
1.
PSYCHOSOCIAL SUPPORT
 If the overall goal of pulmonary rehabilitation is to improve
the quality of patients’ lives, physical reconditioning alone is
insufficient.
 Psychosocial indicators generally are good predictors of
morbidity in patients with COPD.
 There is a well-established relationship between physical,
mental, and social well-being in humans. However,
emotional states such as anxiety and stress can aggravate an
existing physical problem.
 Likewise, physical manifestations of disease, such as
recurrent dyspnea, can increase an individual’ stress level.
CONT:
 Patients with COPD often have a tendency to
develop severe anxiety, hostility, and stress as a
direct consequence of their disability.
 patients are fearful of economic loss and death,
they can develop hostility toward the disease and
often toward the people around them.
 Moreover, patients’ potential loss of confidence
in their ability to care for themselves reduces
feelings of dignity and self-worth.
STRUCTURE OF A PULMONARY
REHABILITATION PROGRAM
PROGRAM GOALS AND OBJECTIVES
Common Goals for Pulmonary  • Psychosocial support
Rehabilitation Programs:  • Occupational retraining
 • Control of respiratory
and placement (when and
infections
 • Basic airway management where
 • Improvement in ventilation and  possible)
cardiac status  • Family education,
 • Improvement in ambulation
counseling, and support
and other types of physical
activity
 • Patient education,
 • Reduction in overall medical counseling, and support
costs  • Control of respiratory
 • Reduction in hospitalizations
infections
PROGRAM GOALS AND OBJECTIVES
 Pulmonary rehabilitation programs vary in their design and
implementation but generally share common goals.
 These general

 goals assist planners in formulating more specific program

objectives.
 Depending on the specific needs of the participants,

program objectives can include the following:

• Development of diaphragmatic breathing skills
• Development of stress management and relaxation
Technique.
PROGRAM GOALS AND OBJECTIVES
 Involvement in a daily physical exercise regimen to condition
both skeletal and respiratory-related muscles
• Adherence to proper hygiene, diet, and nutrition
• Smoking cessation (if applicable)
• Proper use of medications, O2, and breathing equipment (if
applicable)
• Application of airway clearance techniques (when indicated)
• Focus on group support
• Provisions for individual and family counseling.
 When program objectives are specifically defined and structured

in a measurable way, strategies can be tailored to ensure the maximum

results and benefit.
PATIENT EVALUATION AND SELECTION
 Patient Evaluation:
 Patient evaluation begins with a complete patient history—medical,
psychological, vocational, and social. A well designed patient
questionnaire and interview form assist with this step.
 The patient history should be followed by a complete
 physical examination. A recent chest film, resting
electrocardiogram (ECG), complete blood count, serum
electrolytes, and urinalysis provide additional information on the
patient’s current medical status.
 To determine the patient’s cardiopulmonary status and exercise
capacity, both pulmonary function testing and a cardiopulmonary
exercise evaluation may be performed
CONT:
 The cardiopulmonary exercise evaluation (CPX) serves two
key purposes in pulmonary rehabilitation.
 First, it quantifies the patient’s initial exercise capacity. This
quantification provides the basis for the exercise
prescription (including setting a target heart rate) and yields
the baseline data for assessing a patient’s progress over
time.
 In addition, the evaluation helps determine the degree of
hypoxemia or desaturation that can occur with exercise; this
provides the objective basis for titrating O2 therapy during
the exercise program.
 The exercise evaluation procedure involves serial or
continuous measurements of several physiologic parameters
during various graded levels of exercise on either an
ergometer or a
Treadmill.
 To allow for steady-state equilibration, these graded levels

are usually spaced at 3-minute intervals. Work levels are

increased progressively until either (1) the patient cannot
tolerate a higher level or (2) an abnormal or hazardous
response occurs.
 Test preparation must be guided well.
COMMON PHYSIOLOGIC PARAMETERS MEASURED DURING
EXERCISE EVALUATION

 Blood pressure
 • Heart rate
 • ECG
 • Respiratory rate
 • Arterial blood gases/O2 saturation
 • Maximum ventilation.
 • O2 consumption (either absolute !VO2 or METS)
 • CO2 production (V!E/V!CO2)
 • Respiratory quotient (RQ)
 • O2 pulse (VO2:heart rate).
RELATIVE CONTRAINDICATIONS TO EXERCISE TESTING

 Inability or unwillingness of patient to perform the test

 Severe pulmonary hypertension or cor pulmonale
 Known electrolyte disturbances (hypokalemia, hypomagnesemia)
 Resting diastolic blood pressure greater than 110 mm Hg or resting
systolic blood pressure greater than 200 mm Hg
 Neuromuscular, musculoskeletal, or rheumatoid disorders
exacerbated by exercise
 Uncontrolled metabolic disease (e.g., diabetes)
 SaO2 or SpO2 less than 85% with the subject breathing room air
 Untreated or unstable asthma
 Angina with exercise
MINIMIZE RISK:
 To minimize patient risk during exercise evaluation, certain safety
measures are implemented.
 First, the patient should undergo a physical examination just

before the test, including a resting ECG.

 Second, a qualified physician should be present throughout the

entire test.
 Third, emergency resuscitation equipment (cardiac crash cart with

monitor, defibrillator, O2, cardiac drugs, suction equipment, and

airway equipment) must be readily available.
 Fourth, staff conducting and assisting with the procedure should

be certified in basic and advanced life support

techniques.
Last, the test should be terminated promptly whenever indicated.
PATIENT SELECTION
Indications and Contraindications for Pulmonary Rehabilitation
 INDICATIONS
 Symptomatic patients with COPD—usually GOLD stage III
 (severe) and stage IV (very severe), but stage II (moderate) may also be considered
 Patients with bronchial asthma and associated bronchitis (asthmatic bronchitis)
 Patients with combined obstructive and restrictive ventilatory defects
 Patients with chronic mucociliary clearance problems
 Patients with exercise limitations because of severe dyspnea
 CONTRAINDICATIONS
 Cardiovascular instability requiring cardiac monitoring (consider cardiac
rehabilitation)
 Malignant neoplasms involving the respiratory system
 Severe arthritis or neuromuscular abnormalities (a relative
 contraindication—refer to physical therapy for case-by-case review)
PROGRAM DESIGN

 A good design helps achieve specific

programming objectives with the selected group
of participating patients.
 Key design considerations involve both format
and content, with emphasis on patient
reconditioning and education.
FORMAT
 Programs can use either an open-ended or a closed design,
with or without planned follow-up sessions.
 no set time frame. Depending on his or her condition, needs,
motivation, and performance, an individual patient can
complete an open-ended program over weeks or months.
 This format is good for self-directed patients or patients with
scheduling difficulties.
 It also may be the best format for patients requiring individual
attention.
 Major drawback of the open-ended format is the lack of group
support and involvement.
 The more traditional closed design uses a set time
period to cover program content. These programs
usually run 6 to 16 weeks, with Classes meeting one to
three times a week.
 Class sessions usually last up to 2 hours. Presentations
are more formal and group support involvement is
encouraged.
 A major drawback to this format is that the schedule
determines program completion, rather than the
objectives.
SAMPLE PULMONARY REHABILITATION SESSION

COMPONENT FOCUS TIMEFRAME

Educational Welcome (group interaction) 5 MINS
Review of program diaries
(activities of past week) 20 min
Presentation of educational 20 min
topic
Questions, answers, and 15MINS
group
discussion
Physical Physical activity and 45 min
Reconditioning reconditioning
Individual goal setting and 15 min
session summary
TOTAL SESSION 120 MINS(2 HRS)
CONTENT
 The content of the rehabilitation program usually combines physical
reconditioning with education activities.
 Physical Reconditioning
 The physical reconditioning component of the pulmonary
 rehabilitation program consists primarily of an exercise prescription with
target heart rate based on the results of the patient’s initial exercise
evaluation.
 For most patients, an initial target heart rate is set using Karvonen’s
formula, or estimated as 20 beats/min greater than resting rate.
 Target heart rate = [(MHR −RHR) × (50%− 70%)] +RHR
 Typically, the exercise prescription includes the following four related
components.
 1. Lower extremity (leg) aerobic exercises
 2. Timed walking (6- or 12-minute walk)
 3. Upper extremity (arm) aerobic exercises

 EDUCATIONAL COMPONENT: TYPICAL EDUCATIONAL TOPIC SCHEDULE
FOR A 12-WEEK PULMONARY REHABILITATION PROGRAM
Session Topics Facilitators
(Week)
1 Introduction and welcome; program orientation Program administrator or
rehabilitation team
2 Respiratory structure, function, and pathology Physician or RT
3 Breathing control methods PT or RT
4 Relaxation and stress management Clinical psychologist
5 Proper exercise techniques and personal routines PT or RT
6 Methods to aid secretion clearance (bronchial hygiene) PT or RT
7 Home oxygen and aerosol therapy RT
8 Medications—their use and abuse Pharmacist, physician, or
nurse practitioner
9 Medications—use of MDIs and spacers RT
10 Dietary guidelines and good nutrition Dietitian or nutritionist
11 Recreation and vocational counseling Occupational therapist
12 Activities of daily living , Follow-up planning and Rehabilitation team
program evaluation
CONT:
 PROGRAM IMPLEMENTATION
 STAFFING:
 It is recommended that any staff conducting pulmonary rehabilitation
program sessions be certified in basic life support or advanced cardiac life
support through the American Heart Association.
 FACILITIES:
 Ideally, the facility should provide two separate rooms for the program—one
room for educational activities and one room for physical reconditioning.
Rooms should be spacious and comfortable with adequate lighting,
ventilation, and temperature control. Chairs should be comfortable with good
back support. Restroom facilities need to be readily accessible.
 SCHEDULING:
 Most sessions are scheduled one to three times per week for 1 to 2 hours, with
programs running 8 to 16 weeks.
 CLASS SIZE:
 The ideal class size should range from 3 to 10 participants
EQUIPMENT
 To meet the educational needs of the program, a
whiteboard or flipchart, computer with a
PowerPoint projector screen, overhead projector,
and/or CD player are needed.
 For physical reconditioning, stationary bicycles,
treadmills, rowing machines, upper extremity
ergometers, weights, pulse oximeters, and
inspiratory resistance breathing devices constitute
the minimum equipment requirement.
BOX 55-5 FACTORS AFFECTING PULMONARY REHABILITATION
PROGRAM COSTS

• Marketing and program promotion

• Number of personnel involved in program facilitation and
administration
• Space and utility expenses
• Audiovisual, exercise, and monitoring equipment (purchase and
maintenance)
• Production and duplication of course materials
• Patient supplies
• Office supplies
• Refreshments
• Miscellaneous expenses