L8: Pulmonary Rehabilitation

Question 1

What is the definition of pulmonary rehabilitation? What are the aims?

Answer 1

1. A comprehensive intervention, based on a thorough assessment
2. Exercise training, education and behaviour change; tailored to the patient
3. Designed to improve physical and psychological condition of people with chronic respiratory disease
4. Aims to promote long-term adherence to health-enhancing behaviours

Question 2

What are the 2 clinical programs of pulmonary rehabilitation?

Answer 2

1. Outpatient: either hospital or community based
   
   • Emerging evidence with home-based programs
2. Inpatient interventions

Question 3

What are the 2 areas of pulmonary rehabilitation?

Answer 3

1. Traditionally in chronic obstructive pulmonary disease (COPD)
2. Emerging evidence with:
3. Bronchiectasis, interstitial lung disease and pulmonary vascular disease
4. Considered essential pre & post lung transplantation & lung volume reduction surgery

MUST do pre-rehab except if patient is extremely fit or have CF

Question 4

What are the 4 aims of pulmonary rehabilitation?

Answer 4

1. ↓ symptoms
2. Optimise functional status
3. ↑ participation
4. ↓ health care costs

EDUCATION + EXERCISE + SUPPORT

Question 5

What is the clinical presentation, interventions and disease progression in pulmonary rehabilitation?

Answer 5

Question 6

What is the process and content in pulmonary rehabilitation?

Answer 6

Question 7

What are the 7 benefits of pulmonary rehabilitation?

Answer 7

1. ↑ Exercise capacity
2. ↑ Muscle strength
3. ↑ Health-related quality of life
4. ↓ Dyspnoea level
5. Health care utilisation benefits
6. Psychosocial benefits
7. Beneficial for people with other chronic respiratory diseases

Question 8

What are 9 Australian and New Zealand Guidelines for pulmonary rehabilitation?

Answer 8

1. Is PR effective compared with usual care in patients with COPD?
   
   1. Stable disease - Strong recommendation
   2. Early commencement of post-exacerbation PR – Weak recommendation
2. Does pulmonary rehabilitation affect health care utilisation?
   
   1. Moderate-severe COPD - Strong recommendation to decrease hospitalisation for exacerbations
3. Is a community or home-based pulmonary rehabilitation program as effective as a hospital-based pulmonary rehabilitation program?
   
   1. Home-based compared to usual care – Weak recommendation
   2. Home-based compared to hospital/community-based – Weak recommendation
4. In people with mild disease severity, is pulmonary rehabilitation as/more effective as/than usual care? Weak recommendation
5. Are programs of longer duration more effective than the standard eight week programs? Unclear
6. Does ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation program, maintain exercise capacity and quality of
7. life to 12 months?
   
   1. Unclear best model but <1x/month recommended
8. Does a structured education program enhance the benefits of pulmonary rehabilitation?
   
   1. PR offered irrespective of availability of education program - Weak recommendation
9. Do patients who experience oxygen desaturation during exercise have greater improvements if oxygen supplementation is provided during training? Further research is required
   
   1. Is pulmonary rehabilitation effective in chronic respiratory diseases other than COPD?
   2. Bronchiectasis: Yes - Weak recommendation
   3. Interstitial Lung Disease: Yes - Weak recommendation
   4. Pulmonary Hypertension: Yes - Weak recommendation
10. Hard to make patients blinded in research –> that’s why results are weak

Question 9

What are 4 eligibility criteria for pulmonary rehabilitation?

Answer 9

1. COPD or other chronic respiratory disease
   
   • Symptomatic – dyspnoea or fatigue
   • Limited activity levels
2. Willingness to participate
   
   • Even if current smoker
   • Consider motivation, logistical difficulties, etc
3. Cardiovascular disease comorbidity
   
   • Can be referred with coexisting stable disease
4. Anxiety &/or depression should not preclude referral

Question 10

What are 3 exclusion criteria for pulmonary rehabilitation?

Answer 10

1. Severe cognitive impairment or psychotic disturbance
2. Relevant infectious disease
3. From exercise if have:
   
   1. Musculoskeletal or neurological disorders preventing gentle exercise
   2. Unstable cardiovascular disease
   3. Known metastatic cancer

Question 11

What clinically happens in pulmonary rehabilitation?

Answer 11

Question 12

What is 9 assessments in pulmonary rehabilitation?

Answer 12

8 weeks of rehab

1. Diagnosis & co-morbidities
2. Respiratory function
3. Smoking history
   
   • Poorer drop-out rate, while effectiveness is the same
4. Nutritional Status
5. Low BMI is implicated in higher mortality for people with COPD
6. Exercise capacity
7. Quality of life (QOL)
8. Dyspnoea / breathlessness
9. Mental health assessment – anxiety & depression
10. Patient Goals

Question 13

What are 5 outcome measures in the assessment of exercise capacity in pulmonary rehabilitation?

Answer 13

1. Assess level of functional impairment & limitation in activity
2. Evaluate benefits of rehabilitation
3. Determine the factors that limit exercise capacity
   
   • Usually breathlessness, can be leg/muscle fatigue
4. Provide information that will guide exercise prescription
5. Identify O2 desaturation during exercise and assist prescription of supplemental O2

Question 14

What are 5 assessments of exercise capacity in pulmonary rehabilitation?

Answer 14

1. 6MWT (6 min walk test)
2. ISWT (Incremental shuttle walk test)
3. Cardiopulmonary Exercise test
   
   • Provide detailed information on physiological measurements/ limitations
4. Endurance Shuttle Walking Test – ESWT
5. Modified SWT (At a certain speed, can’t walk any faster –> can start to run)

Question 15

What are 3 assessments of exercise capacity (upper limb tests) in pulmonary rehabilitation?

Answer 15

1. Dyspnea levels on activities of daily living
2. Incremental Unsupported Upper limb Exercise Test
3. Grocery shelving test

Question 16

What are 2 assessments of exercise capacity (functional exercise tests) in pulmonary rehabilitation?

Answer 16

1. 6MWT
2. ISWT
3. no functional exercise test assessment

Question 17

What are 3 assessments (questionnaires) of quality of life (QoL) in pulmonary rehabilitation?

Answer 17

1. SGRQ (St George respiratory questionnaire)
   
   1. Symptoms, Activity, impact on social activities & psychological
   2. Self-administered; Lower scores = better health-related QOL
   3. MID = between groups of patients and for changes within groups of patients is four units
2. CRQ (Chronic respiratory questionnaire)
   
   1. Dyspnea, fatigue, emotional function & mastery of disease
   2. Self-administered or interviewer led; Higher scores = better QOL
   3. MID = average of 0.5 per question per dimension
3. CAT (For COPD)
   
   1. 8 questions – cough, phlegm, chest tightness, walk up hill or stairs, limited in activities, confident to leave home, sleep & energy
   2. Score 0 to 5 – higher score is worse
   3. Minimally important difference is not determined

Question 18

What is the assessment of breathlessness in pulmonary rehabilitation?

Answer 18

Question 19

What are 5 assessments of mental health in pulmonary rehabilitation?

Answer 19

1. Hospital Anxiety & Depression Scale (HADS)
   
   • 7 questions each related to anxiety & depression
2. Kessler Psychological Distress Scale (K10)
   
   • 10 item questionnaire about anxiety & depressive symptoms
3. Depression Anxiety Stress Scales (DASS)
   
   • 42 item instrument
4. Other
5. No mental health assessment

Question 20

What are 8 exercise training components in pulmonary rehabilitation?

Answer 20

1. At least 20 minutes (continuous or intermittent)
2. At least 3 times/week
3. At least 6 weeks
4. Higher intensity
   
   1. ↑ physiological benefit
   2. 60-80% peak work rate
   3. Can start at 80% 6MWD (sub-maximal test)
   4. Can use interval training if symptomatic
5. Training of ambulatory muscles (i.e. LL endurance exercise)
6. Strength training increases muscle strength and mass
7. Unsupported UL endurance training is beneficial (eg. washing hair, carrying objects)
8. Routine use of inspiratory muscle training is not supported
9. 10. Make sure to monitor symptoms

Question 21

What are 5 strength exercise training components in pulmonary rehabilitation?

NOT IN EXAM?

Answer 21

1. Specificity - dynamic resistance best
2. Overload - ↑ resistance / load
3. Dose - 6-12 Repetition maximum (RM)
4. Older adults - 10-15RM
5. Minimal added gain when > 1 set (aim 1-3 sets recommended)
6. Avg. 6/12 gain – 25-30%

Question 22

What are 4 intensity exercise training components in pulmonary rehabilitation?

Answer 22

1. Lower extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD
2. Both low and high intensity exercise training produce clinical benefits for patients with COPD
3. The minimum exercise intensity ‘threshold’ that will result in adaptation remains elusive
4. Clinically important to consider what the patient wants to achieve in the period of supervised exercise training

Question 23

What are 4 walking exercise training components in pulmonary rehabilitation?

Answer 23

1. Six-minute walk distance (6MWD) ÷ 6 = Distance in one minute
2. For distance in 30 minutes = one minute distance x 30
3. For distance in 20 minutes = one minute distance x 20
4. For distance in 10 minutes = one minute distance x 10 etc…

Note: The patient would not be expected to keep up the same walking pace throughout the walking training session that they achieved in the 6MWT. Therefore, prescribe approximately 80% of the calculated distance.

1. Treadmill speed = 80% 6MWT average speed
2. 6MWT average speed = (6MWT distance x 10) ÷ 1000 km/hr

Question 24

What are 4 cycling exercise training components in pulmonary rehabilitation?

Answer 24

1. Cycling training intensity can be calculated from equations using the participants 6MWD to estimate the initial work rate
2. ATS/ERS Pulmonary Rehab statement 2013 does not recommend this approach
3. Equations use age, height, weight and sex in estimating the peak cycle work rate
4. However, the association between peak work rate and 6MWD only explained approximately 40% to 67% of the variation

Question 25

How to manage transient exertional desaturation?

Answer 25

1. It is generally accepted that those who have met the criteria for long-term oxygen therapy (LTOT) should use supplemental oxygen when exercising 2. The challenge is managing those who have acceptable arterial oxygen saturation at rest, and therefore do not meet the requirements to be prescribed LTOT, but who demonstrate severe transient exertional desaturation 3. The level of desaturation tolerated by clinicians delivering a pulmonary rehabilitation program is arbitrary, and differs greatly between programs 4. Some programs offer supplemental oxygen 5. Some programs attempt to minimise desaturation by implementing an interval or intermittent training program Guided by breathlessness Risk of exercise is LESS than the risk of not exercising

Question 26

What are 4 ways to manage exertional breathlessness?

Answer 26

1. Bronchodilators 2. Recovery positions 1. If they are in these positions --\> are usually already quite breathlessness 3. Managing anxiety of breathlessness 4. Make sure physio does not panic --\> be calm 5. Breathing strategies 1. Relaxed breathing 2. Prolonged expiration breathing (e.g. Pursed lip breathing) 3. Combined = can be effective 6. Teach client to pace themselves 1. “If you go slowly and pace yourself, you will go a lot further before needing a rest” 2. Easier to walk slowly to manage breathlessness 3. Try to establish a pattern of breathing that matches the exertion required 4. For example when stair climbing or walking up hills 1. Encourage client to catch their breath first 2. Find a rate of breathing that matches their effort 3. If activity is too hard, simply stop and recover before restarting at a slower pace 4. Gaining breathing control will help with anxiety

Question 27

What is the exercise training duration of 4 weeks for pulmonary rehabilitation?

Answer 27

Question 28

What is the exercise training duration of 6 months for pulmonary rehabilitation?

Answer 28

Question 29

What are 3 maintenance exercise training components in pulmonary rehabilitation?

Answer 29

1. 6-12 weeks pulmonary rehabilitation * Benefits that decline gradually over 12-18 months * Health related QOL remain above control at 12-18 months 2. \>12 weeks pulmonary rehabilitation * produce greater sustained benefits than shorter programs 3. Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes 4. Weekly community-based maintenance exercise + HEP - supervised by a physiotherapist

Question 30

What is the physical activity levels in COPD?

Answer 30

Question 31

What are 3 post-acute exacerbation for exercise training components in pulmonary rehabilitation?

Answer 31

1. Early pulmonary (exercise) rehabilitation post-acute exacerbation appears important 1. ↓ mortality & hospital re-admissions 2. ↑ exercise capacity & quality of life 3. No clear consensus on training program 2. Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations 3. Resistance training is safe 4. Counteracts skeletal muscle dysfunction 5. May up-regulate the anabolic response in the skeletal muscle

Question 32

What are 4 other exercise training considerations in pulmonary rehabilitation?

Answer 32

1. Supplementary O2 2. Non-invasive ventilation 3. Heliox * Reduce resistance to air 4. Anabolic steroids * Performance enhancing --\> risks are higher than benefits

Question 33

What are 3 characteristics of variability in response in pulmonary rehabilitation?

Answer 33

1. Participants can get clinically meaningful gains in dyspnoea, fatigue, health-related quality of life and exercise capacity 2. However, there is clear evidence that the response varies considerably between individuals 3. Approximately half of all people with COPD who complete a pulmonary rehabilitation have only a moderate or minimal response to pulmonary rehabilitation

Question 34

What are 3 different criteria used when defining response in pulmonary rehabilitation?

Answer 34

1. Investigator driven (different thresholds) 2. Participant’s opinion 3. Clinician’s opinion

Question 35

What are 5 system factors may affect response when defining response in pulmonary rehabilitation?

Answer 35

1. Program location 1. Distance to travel, public transport availability & suitable car parking 2. Timing 1. Preference for exercise, other commitments 3. Program reimbursements 4. Recommendation to attend the program from an influential person to the individual 5. Interaction between therapist and participant

Question 36

What are 3 better responses in exercise capacity as a likely responder in pulmonary rehabilitation?

Answer 36

1. Lower baseline quality of life1 2. Greater quadriceps contractile fatigue2 3. Higher 6MWD 4. Comorbidities

Question 37

What are 3 characteristics of program non-completion in pulmonary rehabilitation?

Answer 37

1. Non-completion rates – around 20-30% 2. Variability in definition of a non-completer 3. Variability in program structure 1. Program length: 10 sessions to 12 weeks duration 4. Factors associated with program non-completion 1. Live alone or lack social support at home4 2. Depressed 3. Quadriceps weakness 4. Transport difficulties 5. Weather