PULMONARY REHABILITATION

GENERAL MEDICAL BACKGROUND

I.

DEFINITION
Pulmonary conditions are any disorder
affecting the function of the respiratory
system.
Pulmonary rehab is a multidisciplinary
program of care for patients with chronic
respiratory impairment that is individually
tailored and designed to optimize physical
and social performance and autonomy.
Pulmonary rehabilitation includes post surgical
management of lung and heart-lung
transplants

Inspiratory Capacity = 3500 mL

Functional Residual Capacity = 2500 mL
Vital Capacity = 4500 mL
Total Lung Capacity = 6000 mL

CLASSIFICATIONS

A.

Chronic Obstructive Pulmonary Diseases

Restrictive Lung Diseases

COPD (intrinsic disorder, oxygenation

impairment)

RESPIRATORY TRACT

Upper Respiratory Tract

1. Nose
2. Pharynx
a. Nasopharynx
b. Oropharynx
c. Laryngopharynx
3. Larynx
a. Voice box
Lower Respiratory Tract
1. Trachea
2. Main Bronchi
3. Lobar Bronchi
4. Segmental Bronchi
5. Terminal Bronchioles
6. Respiratory Bronchioles
7. Alveolar ducts
8. Alveolar sacs
9. Alveoli
10. Capillaries

Tidal Volume = 500 mL

Inspiratory Reserve Volume = 3000 mL
Expiratory Reserve Volume = 1000 mL
Residual Volume = 1500 mL

II.

Review on Anatomy and Physiology

Function of the pulmonary system:

a. Ventilation
b. Respiration
External
Internal
c. Perfusion
d. Transportation & Diffusion of O2 and CO2

I.

Airflow limitation that is not fully irreversible

Combination of airway narrowing,
parenchymal destruction, and pulmonary
vascular thickening which impede the rate
of flow into and out of the lungs
Any conditions that obstruct airflow in the
respiratory tract and affects ventilation and
respiration
Characterized by an increase in airway
resistance that is measured as a decrease in
peak expiratory flow rates
Airflow limitation is usually both progressive &
associated with an abnormal inflammatory
response of the lungs to noxious particles or
gases
Can affect both mechanical function and gas
exchanging capacity of the lungs
Etiology
Genetic predisposition
Environmental factors ( allergic diseases ,
e.g. asthma)
Chemical inflammation (e.g. cigarette smoke,
asbestos)
Metabolic abnormalities (e.g. alpha 1antitypsin deficiency)
Cigarette smoking (main cause: chronic
bronchitis, emphysema)
Smokers are 3.5-25 times more likely
(depending on amounts smoked) to die of
COPD than non-smokers

MUSCLES OF RESPIRATION

LUNG VOLUMES & CAPACITIES

Epidemiology

Affects 10 40 % of all Americans

th

the 5 leading cause of death in the IS and its

incidence has doubles since 1970
th

Worldwide, respiratory diseases are the 4

leading cause of death

Chronic respiratory diseases are a leading

cause of major limitation of activity, loss of
work days and premature retirement due to
disability

Respiratory disease is the most common

cause of early death in traumatic quadriplegia
and neuromuscular disorders

COPD and asthma most common lung

disease for which pulmonary rehabilitation is
rendered

1)
II.

Pathophysiology

Changes Associated with Obstructive Lung Diseases:

Airway obstruction is the primary pathophysiologic

mechanism which can be caused by:
Reversible factors
Inflammation of the airways
Bronchospasm
Mucus plugging or Increased production &
retention of mucus
Irreversible factors
Fibrotic airway
Damaged alveoli & bronchial walls
Localized lesions

All of these conditions decrease the size of the air

passages

Due to airway obstruction, both expiratory and

inspiratory flow rates are decreased, which
decreases gas exchange between the alveoli and
capillaries

Abnormal pulmonary function tests:

decreased expiratory reserve volume
increased residual volume
decreased expiratory flow rates

CHRONIC BRONCHITIS
Excessive mucus production in the bronchial
tree with a chronic or recurrent productive
cough that lasts at least 3 months and recurs
over at least 2 consecutive years.
I.

Etiology
Cigarette smoking
Air pollution
Second-hand smoke
Occupational exposure to dusts, such as
gold, coal, fluorspar and asbestos

Epidemiology
M>F
>50 years old

II.

III.

IV.

Because of decreased gas exchange, respiratory

volumes must be increased to compensate for
this, thus more energy expenditure is necessary
for breathing
There is dilatation and destruction of the
respiratory bronchioles.
Also other changes include the loss of normal
elastic recoil properties of the lungs.
(+) hypoxemia
(+) hypercapnia
Patients become hypoxic, despite being normally
eucapneic or hypocapneic

**During normal inspiration, the lungs and the

airways are pulled open, increasing the diameter
of the lumen. In exhalation, the thorax then return
to its resting position.
BUT.
In COPD, airways are opened wide by thoracic
expansion, allowing air to enter.
During Exhalation, the airway narrowing from
inflammation, remodeling and excessive
secretions causes premature airway closure
causing hyperinflation.
III.

Clinical Presentation
Chronic cough
Expectoration
Exertional dyspnea
Thorax appears enlarged (barrel chest)
Flattened diaphragm
Hypertrophy of the accessory muscles
Cyanosis
Digital clubbing

2)

I.

Etiology
Can be acquired through smoking
Can also be congenital (genetic
abnormality of the long arm of
Chromosome 14)
Hereditary deficiency of alpha1antitrypsin (inhibits the enzyme,
neutrophil elastase)
Elastin helps the alveolar wall to be
more permeableto gases

II.

III.

COPD Conditions:
Chronic Bronchitis
Emphysema
Asthma
Bronchiectasis
Cystic Fibrosis

Clinical Manifestation
Mild to moderate dyspnea
More prominent cough
Copious and purulent sputum
Frequent bronchial infection
Cyanotic
Patients are commonly obese and have
edema
Blue Bloaters

EMPHYSEMA
Overdistention of the air spaces (alveoli)
distal to the terminal bronchioles with the
destruction of the alveolar septa

Pathophysiology
Causes hypertrophy and hyperplasia of
goblet cells
Narrowing of airways because of chronic
inflammation & partial obstruction of the
bronchial tree and thickening of the lining.
Decrease in number and action of the
ciliated epithelial cells that mobilize & help
clear secretions
(+) Dirty lung appearance

IV.

Epidemiology
>60 year old
M>F
Pathophysiology
overinflation of the lungs & formation of
pockets of air, known as bullae
destruction of alveoli & loss of area in
which effective gas exchange occur
Lung tissue loses its elasticity
airway obstruction & pulmonary structural
destruction
Lungs remain overinflated; diaphragm
flattens, less effective
Clinical Manifestation
More severe dyspnea
Less prominent cough
Scanty & mucoid sputum
(+) barrel chest
(+) hyperinflation
Less frequent bronchial infection
Hypertrophied accessory muscles of
respiration
Pink Puffers

3)

ASTHMA
Characterized by episodic periods of
reversible airway narrowing in the presence
of aeroallergens, irritants and exercise.
The narrowing is due to inflammation,
bronchospasm and increased airway
secretions
I.

Etiology
Triggering Factors

Pollen

Dust

Food

Animal hair

Irritant inhalants (paint)

Climate change

Exercise
Others: Genetic predisposition

II.

III.

IV.

4)

II.

III.

5)

I.

II.

Pathophysiology
Gene defect causes the secretions of the
exocrine glands to be thick and viscous

III.
Clinical Manifestations
Productive cough
Bronchial infections
Weight loss
Increased NaCl in sweat
(+) Honeycomb lungs
Decreased breath sounds with adventitious
sounds of crackles and wheezes

Cyanosis and digital clubbing may be present

Clinical Manifestations
Triad: Coughing, wheezing and dyspnea
Accessory muscles of ventilation are
used for breathing
May be barrel chested
Mainstay treatment: Nebulization
Most severe form of asthma: status
asthmaticus

Epidemiology
An estimated 110,000 individuals have
bronchiectasis in the United States
The prevalence of bronchiectasis increases
with age
W>M

Etiology
Cystic fibrosis is an autosomal recessive
genetic disease caused by mutations in the
gene, specifically the long arm of
chromosome 7

Pathophysiology
Widespread narrowing of the airways in
response to a trigger.
The narrowed airways increase the
resistance to airflow and cause air
trapping, leading to hyperinflation
Abnormal distribution of ventilation to the
alveoli occurs

Etiology
Necrotizing infection or a series of multiple
infections involving the tracheobronchial
walls and adjacent lung parenchyma
Bronchial obstruction
Bacterial pneumonias
Staphylococcus aureus
Klebsiella pneumonia
Pseudomonas aeruginosa

Clinical Manifestation
Cough
Recurrent pulmonary infections
Putrid sputum
Sputum separates into three layers in
standing
Upper layer: white/slightly greenish
brown frothy secretions
Middle thin mucoid layer
Bottom layer of thick greenish plugs

CYSTIC FIBROSIS
Cystic fibrosis (CF) is a multisystem disorder
involving the exocrine glands.
Aka Mucoviscidosis
Triad:

Bronchial mucus glands

Sweat glands

Exocrine cells of pancreas

Epidemiology
50%, <10 years old, M>F with a ration of
2:1
But symptoms may appear at any age

BRONCHIECTASIS
Bronchiectasis is a permanent, abnormal
dilation and distortion of one or more bronchi
that is caused by destruction of the elastic
and muscular components of the bronchia
walls.
I.

IV.

B.

RLD (mechanical disorder, ventilatory

impairment)
Definition

Conditions which cause a reduction in the

functional volume of the lungs

Difficulty in lung expansion

Characterized by an increase of the force
trying to collapse the lung (recoil) and a
decrease in lung compliance, measured as a
decrease in all lung volumes

Decrease in lung compliance

Restriction may be due to:

Diseases of the alveolar parenchyma or

pleura

Chest wall changes

Neuromuscular changes

These can be subdivided into:

a. Parenchymal
Restrictive disorders affecting the lung
tissue itself

Pathophysiology
Prolonged bronchial obstruction increases
the risk of secondary infection which results
in destruction of the bronchial walls and
dilation of the bronchi leading to reparative
laying down of the fibrous tissue.
repeated infections of the lower lobes of
the lungs
destruction of ciliated epithelial cells in
infected areas
accumulation of copious, purulent
secretions

Common examples:
Post-thoracotomy
Pneumonia
Atelectasis

b.

Other examples
Sarcoidosis
Idiopathic pulmonary fibrosis
Pneumoconiosis
Drug- or radiation induced interstitial
lung disease
Extraparenchymal

Smoking most common

Exposure to infectious organism
Virus
bacteria

Occupational exposure to:

Asbestos

Silicon dust

Coal dust

Byssinium

Grain dust

Moldy hay

Disorders outside of the respiratory

system that restrict lung compliance
indirectly
Examples:
Neuromuscular conditions
Diaphragmatic weakness/paralysis

Myasthenia gravis
Guillain-Barre syndrome
Muscular dystrophies
Musculoskeletal conditions
Cervical spine injury
Chest wall injury
Kyphoscoliosis
Obesity
AS

II.

Anatomically, these disorders can be classified into:

a. Upper Respiratory tract
- Commonly used in the context of infectious
respiratory disease

Examples:

Rhinosinusitis (common cold)

Sinusitis

Pharyngitis / tonsillitis

Acute bronchitis

b. Lower respiratory tract

- Commonly used in the context of infectious
respiratory disease
Examples:

Pneumonia

Tuberculosis
c. Parenchymal
- Disorders affecting the lung tissue directly

Examples:

Pulmonary edema

Pulmonary embolism

Pulmonary hypertension

I.

b.

Exposure to environmental agents (more

common) such as:

III.

Clinical Presentation
Dyspnea
Non-productive cough is often encountered
Rapid, shallow breathing
Limited chest expansion
Crackles
Residual volume is normal or near normal

1)

Pulmonary TB
Pneumonia
Pleural Effusion
Pneumothorax
Pulmonary Embolism
Pulmonary Edema
Atelectasis

PULMONARY TB
Tuberculosis is caused by bacteria that most
often affect the lungs.
Cause: Mycobacterium tuberculosis
Has 2 phases
a. Phase I
infection
Flu-like symptoms

Etiology
Radiation therapy
Inorganic dust
Inhalation of noxious gases
Toxicity
Decreased mobility of the chest wall
Neuromuscular apparatus defect

Each pulmonary disorder has its own etiologic

factors.
However these can be generally classified into:
a. Hereditary/Genetic causes (less common)
such as:

Alpha 1 antitrypsin deficiency

Mutation of the cystic fibrosis

transmembrane

regulator(CFTR)

Because of poor mechanical compliance,

the lung cannot normally expand nor return
to resting size
Reduction of lung volume
Hypoxia occurs only secondarily

RLD CONDITIONS:

Extraparenchymal
Disorders outside of the respiratory system
that affect the lung tissue indirectly
Vascular
Disorders affecting the vascular system of
the lungs

Pathophysiology
The particular changes occuring within the
lung tissue and pleura depend on the
etiological factors of restrictive disease
Decreased mechanical compliance is the
primary pathophysiologic mechanism which
can either be caused by poor mechanical
compliance of:
The lung tissue itself (parenchymal)
Structures surrounding the lung
(extraparenchymal)

b.

2)

Phase II
Flu-like symptoms
Decrease in weight
Hemoptysis
(+) night sweats

Maximally infectious for the first 2 weeks

Incubation period is needed for 2-10 weeks
Treatment may last for 3-12 weeks
Patient must be isolated in a negative pressure
room
Observe proper standard precautions when
treating TB patients
PNEUMONIA

May arise if lung disease is not managed as

early as possible, such as:

Decreased CV and pulmonary

endurance

Increased risk of contracting infectious

pulmonary conditions

Death due to pulmonary arrest

Intra-alveolar infection of the lung

parenchyma

Types:
a. Bacterial
b. Viral
c. Aspiration
**(-) Gag reflex uses NGT
IV.

Community Acquired Pneumonia

Haemophilus influenzae
Streptococcus pneumoniae
Hospital Acquired Pneumonia
Pseudomonas aeruginosa

Signs and Symptoms:

Chills

Fever

Productive cough

Dyspnea

3)

PLEURAL EFFUSION
Conditions affecting the pleural space
Excessive fluid accumulation on the lungs
There is limited lung expansion
S/Sx:

Pleural rub

dyspnea

dull or sharp pain

4)

PNEUMOTHORAX
Air/gas leaking in the pleural space
Types:

Traumatic

Iatrogenic

Spontaneous
S/Sx:

Sudden sharp pain

Dyspnea

5)

PULMONARY EMBOLISM
Lodging of small or large particles into the
pulmonary venous circulation
MC cause: DVT
Other causes:

Clotting d/o

Oral contraceptives

Venous stasis

Air due to trauma

S/Sx:

Sudden acute pain

Dyspnea

Coughing

(+) Fever

6)

PULMONARY EDEMA
Water enters alveoli due to unequal capillary
pressure
Associated with:

Left sided heart disease

CHF

Mitral valve disease

S/Sx:

(+) crackles - Cough

Dyspnea Fever

7)

III.

ATELECTASIS
Lung collapse
2 types:
a. Primary (aka Compressive Atelectasis)
b. Secondary (aka Obstructive Atelectasis)

----- X end of pulmo conditions X ----COMPLICATIONS

DIAGNOSIS

History
Family history of lung disease
Exposure to environmental agents
(smoking, occupational)
Presence of coexisting disease
Inspection rate and pattern of breathing,
depth and symmetry of lung expansion
Palpation- vibration produced by spoken
sounds is transmitted to the chest wall and is
assessed by the presence or absence and
symmetry of tactile fremitus
Percussion relative resonance or dullness
of the tissue underlying the chest wall.
Normal sound : resonant
Auscultation examiner listens to both the
quality and intensity of breath sounds
Laboratory examination
o Imaging studies

Chest x-ray

CT scan

MRI

Scintigraphic imagine

Pulmonary angiography

Chest ultrasound
o Examination of biologic specimen

Sputum collection

Percutaneous needle aspiration

Thoracentesis
o Viewing techniques

Thoracotomy

Video assisted viewing techniques

Thoracoscopy

Mediastinoscopy
o Gas analysis techniques

Pulmonary function testing

Arterial blood gas analysis

Pulse oximetry

Pulmonary Assessment
The assessment of the patients pulmonary status has
several purposes:
1. To evaluate the appropriateness of the patients
participation in a pulmonary rehab.
2. To determine the therapeutic measure most
appropriate for the participants in the treatment
programs.
3. To monitor the participants physiologic response
to exescise.
Physical assessment
1. Vital Signs
2. Observation, Inspection, Palpation a normal
configuration of the thorax reveals a ration of
anteroposterior to lateral diameter of 2:1.
3. Auscultation of the lungs involves listening over
the chest wall to the airways as gas enters and
exits the lungs. To perform auscultation, a
stethoscope is placed firmly on the patients
thorax over the lung tissue. The patient is asked
to inspire fully through an open mouth then to
exhale quietly. Note if wheezes, rales, or any
abnormal sounds are present.

4.

V.

Laboratory test include chest radiographs,

pulmonary function, graded exercise tests, arterial
blood is analysis, oxygen saturation.

DIFFERENTIAL DIAGNOSIS

Lung conditions are differentiated using the following

bases:

Physiologic basis
Obstructive vs. restrictive

Anatomic basis
As to actual structure affected

Etiologic basis
As to etiologic agent causing the disease
VI.

PROGNOSIS
Although a comprehensive rehabilitation
program may have little effect on the rate of
progress of the underlying disease, a number of
beneficial effects have been documented
including:
Reduction in the average number of
hospitalization days per year
Subjective improvement in symptoms
and quality of life

GENERAL HEALTHCARE MANAGEMENT

I.

Medical, surgical, & pharmacologic

Treatment Goals

To provide ongoing secretion removal to optimize

respiration.

To initiate exercises training to improve present

level of function.

To promote self-management of pulmonary

disease.

To improve patient and family education.

Medical Management

Smoking cessation
Major causal agent in COPD
Most important intervention
Nicotine replacement therapies
Pharmacological interventions

Bronchodilators

Steroids

Antihistamine

Albuterol, Ventolin

Antibiotic therapy

Supplemental oxygen
Oxygen saturation should be maintained (>94%)
Surgical Management

Lung Volume Reduction Surgery (LVRS)

Lung Transplantation
COPD patients do not usually undergo surgery
because of the disease itself but if the patient must
undergo surgery for other conditions COPD may affect
the persons response to anesthetic and ability to cope
with respiratory problems after surgery.
In preparation for surgery the pulmonary status of
persons with COPD will be carefully evaluated and
measures will be instituted to improve ventilation and
perfusion. Persons with chronic pulmonary problems
must be monitored very carefully during surgery and in
the early post-op period.

PHYSICAL THERAPY EXAMINATION,

EVALUATION, & DIAGNOSIS
I.

Points of Emphasis during Examination:

Purposes of Examination:

To evaluate the appropriateness of the patients

participation in a pulmonary rehab

To determine the therapeutic measure most

appropriate for the participants in the treatment
programs.

To monitor the participants physiologic response

to exercise
Pts perform additional examination techniques of the
following:

Regular vital signs assessment

Endurance testing using either of the following:

Walk test ambulate as far as possible in

12 minutes

Cycle test begin with 100 kpm, increase

100 kpm

Treadmill test constant 0 grade

Rate of Perceived Exertion Scale (Borg)
Shortness of Breath Scale
Chest expansion measurement
Neurologic system - Check for any signs of
neuromuscular involvement
Musculoskeletal System
a. Joint play of chest wall articulations:

Sternum

Vertebrae

Ribs
b. ROM:

Chest wall

Shoulder
Cervical
Lumbar
c. MMT:

Primary and accessory muscles of

respiration
d. Limb girth measurements

Only if vascular conditions of pulmonary

origin are suspected
e. Posture
Note particularly for:

Scoliosis

Kyphosis

Lordosis

Other trunk deformities

f. Functional assessment
Check both basic and instrumental ADL
Moser Classification of Functional Pulmonary
Disability

Patient History

complaint is shortness of breath

Baseline Dyspnea Index

Occupational, social, medication and family

histories should be recorded
Test and Measures
Vital Signs
Observation, Inspection and Palpation
Use of accessory muscles of ventilation
Normal configuration of thorax (AP-Lat Diameter)
Symmetrical chest expansion
Cyanosis & digital clubbing
Auscultation
Measurement of strength

Exercise Testing
There are a number of test protocols available to
assess the functional ability of patients with pulmonary
disease.
1. Walk test ambulate as far as possible in 12
mins.
2. Cycle test begin with 100 kpm , increase 100
kpm
3. Treadmill test constant 0 grade.
Diagnostic Testing
1. Spirometry
2. Chest x-ray / Radiography
3. CT-Scan
4. Blood count

PHYSICAL THERAPY PROGNOSIS, PLAN OF

CARE & INTERVENTIONS
I.

Graded Exercise Test Termination Criteria

Maximal Shortness of breath

Symptoms of fatigue

Increase in diastolic blood pressure of 20 mmHg

Systolic hypertension of greater than 250mmHg

Decrease in blood pressure with increasing

workloads

Leg pain

Total fatigue

Assess the rate of exertion

Borgs Scale
Rating of Perceived SOB

II.

PROBLEM LIST
Impaired airway clearance 2 to difficulty in
expectoration (coughing) of mucus

Impaired ventilator function leading to poor gas

exchange 2 to either:
a. Parenchymal dysfunction due to:
Impaired mechanical compliance of
lung tissue
b. Extraparenchymal dysfunction due to:
Impaired chest wall articulation joint
play
Pain on chest wall motions

Impaired aerobic capacity/endurance

Easy fatigability

III.

PT diagnosis (Refer APTA refereed pattern)

Primary prevention/risk reduction for
cardiovascular/pulmonary disorders
Usually for at risk patients

Impaired aerobic capacity/endurance

associated with deconditioning
For severely debilitated patients

Impaired ventilation, respiration/gas exchange

and aerobic capacity/endurance associated with
airway clearance dysfunction
For obstructive conditions

Impaired ventilation, respiration/gas exchange

associated with ventilator pump dysfunction of
failure
For restrictive conditions

Plan of Care
Improve airway clearance through
Efficient expectoration of Mucus
Involvement of patients caregiver in airway
clearance techniques
Improve ventilation through
Increasing chest wall articulation joint play
Decreasing pain during chest wall motions
Improve aerobic capacity endurance
Prevent fatigability
Intervention

II.

Impaired ventilation and respiration/gas

exchange associated with respiratory failure
For severe cases undergoing respiratory
failure and patients with Acute Respiratory
Distress Syndrome (ARDS)
Impaired ventilation, respiration/gas exchange
and aerobic capacity/endurance associated with
respiratory failure in neonate
For severe cases undergoing respiratory
failure and patients with Infantile
Respiratory Distress Syndrome

Aerobic /endurance training

Patient is encouraged to apply breathing
techniques during these exercises
Do not exercise to point of fatigue
Graded Exercise Test Termination Criteria
may also be used during these exercises to
decide if immediate termination of exercise
is necessary
check-in period
Warm-up
Aerobic exercise
Cool-down
**perform stretching before exercising
Strength training
Splinting
If pain with chest motions are noted
Could be through:
Applying elastic bandages around
chest area
Manual chest splinting
Exercise progression
Program duration
Home exercise program
Patient Education
Pacing
PJM of chest wall articulations
If presence of impaired chest wall
articulation joint play is found

Breathing Exercise
a. Diaphragmatic breathing
b. Segmental Breathing
c. Pursed-lip breathing

Airway clearance techniques:

a. Postural drainage
Caregivers must be trained on this
b. Manual chest percussion
c. Caregivers must be trained on this
Mechanical chest vibration
d. Using handheld vibrating devices such as
vibrating massagers
e. Caregiver must be trained on this
Coughing techniques
f. Controlled coughing
g. Assisted coughing