Pulmonary Rehabilitation Dr Nishtha

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• Dr Nishtha Singh
• Executive Director Senior Pulmonary Consultant
• Asthma Bhawan, Jaipur

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What does rehabilitation actually means?

• The process of returning to a healthy or good way
  of life, or the process of helping someone to do
  this after they have been not well..

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When is Rehab advised?
COPD/ILD patient
Injury
Physically handicapped patient
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A new indication emerged 2 years back..
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• We faced a new challenge..

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POST COVID COMPLICATIONS

• The Unknown Journey Ahead
• Variable long term outcomes of the patients who
  have recovered from COVID-19

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• Long Covid Support

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What works and what doesnt ?
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Where does PR comes in picture? Indications of PR
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Pulmonary Clinic- Results too good to be true?
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Outline
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Definition- ATS-ERS statement 2013

• Pulmonary rehabilitation (PR) is a comprehensive
  intervention based on a thorough patient
  assessment followed by patient-tailored therapies
  that include, but are not limited to, exercise
  training, education, and behavior change,
  designed to improve the physical and
  psychological condition of people with chronic
  respiratory disease and to promote the long-term
  adherence to health-enhancing behaviors

Spruit MA et al. Am J Respir Crit Care Med 2013.
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Background

• Amidst COVID-19 pandemic the need for pulmonary
  rehabilitation is reiterated
• Patients suffering chronic respiratory conditions
  and COVID-19 survivors often report similar
  symptoms such as
• Pulmonary Rehabilitation is a comprehensive,
  multidisciplinary intervention designed to
  improve the physical condition of people with
  respiratory disease to support their recovery

Decreased functional performance
Hypoxemia
Difficulty performing ADLs
Muscle weakness
Persisting symptoms
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Dysnoea management
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Need for Pulmonary Rehabilitation in COPD

• Pulmonary Rehabilitation is identified as a
  non-pharmacological intervention for management
  in COPD due to

Progressive dyspnea

• due to hyperinflammation and air trapping in
  lungs causing air flow limitation

Peripheral muscle dysfunction resulting from
physical inactivity

• Exercise intolerance is the most common symptom
  in COPD patients leading to peripheral muscle
  deconditioning

Systemic inflammation and reduced exercise
capacity (deconditioning) causing loss of muscle
mass
Corhay, J. L., et.al. (2014). Pulmonary
rehabilitation and COPD providing patients a
good environment for optimizing
therapy. International journal of chronic
obstructive pulmonary disease, 9, 2739.
https//doi.org/10.2147/COPD.S52012
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Need for Pulmonary Rehabilitation in COVID-19

• 80 of patients progress to have ground-glass
  opacities, vascular thickening, bronchiectasis,
  pleural effusion and other manifestation.
• ICU admission, oxygen support, intubation, and
  use of steroids and other medications cause
  physical deconditioning and muscle weakness.
• Increasing evidence suggests post COVID-19
  patients have persistent symptoms, dyspnea and
  difficulty in managing activities of daily living
  thereby affecting their Quality of Life(QOL)

Alteration in lung structure and function
Post Intensive Care Syndrome (PICS)
Impaired Quality of Life
https//www.hopkinsmedicine.org/health/conditions-
and-diseases/coronavirus/what-coronavirus-does-to-
the-lungs
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Need for Pulmonary Rehabilitation in COVID-19

• The purpose of pulmonary rehabilitation in
  COVID-19 patients is to improve symptoms of
  dyspnea, relieve anxiety, reduce complications,
  minimize disability, preserve function, and
  improve quality of life.

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Out patient mild disease management

• Mild disease is defined as mild symptoms without
  pneumonia manifestations on imaging.
• Rehabilitation for mild disease can be managed in
  the outpatient setting using telemedicine.

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Out patient mild disease management

• Expectorant hygiene into closed container
• Huff cough

• Techniques diaphragmatic breathing, pursed lip
  breathing, active abdominal contraction, yoga,
  pranayam, singing
• Frequency 2-3 times/day, daily
• Duration 10-15 mins for 1st 3-4 sessions
• Progression incrementally increase duration
  every 2-3 sessions toward a total goal duration
  of 30-60 mins

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Diaphragmatic breathing
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Airway Clearing

• Autogenic drainage is a common technique that
  uses a combination of the maneuvers to mobilize
  and centralize secretions with
• -short breaths to collect secretions in
  peripheral airway
• -followed by normal breaths to collect secretions
  into the intermediate airway
• -deep breaths and huff cough to expel secretions.
• Application of airway clearance techniques can
  significantly reduce the need for ventilatory
  support, days of mechanical ventilation, and
  hospitalization.
• External vibration if available may be applied
  with oscillation frequencies less than 17 Hz to
  improve mucociliary clearance.

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Pursed Lip Breathing
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Moderate-severe disease management

• Moderate to severe disease is defined as
  symptomatic patients with or approaching
  respiratory distress with RRgt30/min, SpO2 at
  restlt93, or PaO2/FiO2 lt300 mm Hg. These patients
  require hospitalization and monitoring.
• PR includes bed mobility, sit to stand,
  ambulation, breathing rehabilitation exercises.

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Moderate-severe disease management

• In acute exacerbation of chronic lung conditions,
  PR results in moderate to large effects on
  health-related quality of life and exercise
  capacity.
• Exclusion criteria include the following
• body temperature of greater than 38.0C
• initial diagnosis time or symptom onset of 3 days
  or less
• initial onset of dyspnea of 3 days or less
• chest image progression within 2448 hrs of more
  than 50
• SpO2 lt90
• BPlt90/60 mm Hg or gt180/90 mm Hg
• RRgt40/min
• HRlt40 beats/min or gt120 beats/min
• new onset of arrhythmia and myocardial ischemia
• altered level of consciousness.

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Prone Ventilation

• Anecdotal evidence in hospitals suggesting prone
  positioning during acute care of COVID-19 patient
  has been beneficial.
• We recommend time in all positions including side
  lying, upright, supine, and prone and guided by
  imaging findings when possible.
• Targeted positions may be determined by the
  location of consolidations seen on imaging or
  found on examination.
• Prone positioning may aid in ventilation to
  dorsal lung through reduction in lung compression
  by the heart in the semi-prone position because
  of ventral displacement of the heart with
  increases in end-expiratory transpulmonary
  pressure and expiratory reserve volume, more
  homogenous lung inflation from dorsal to ventral
  and improvement in oxygenation.
• Prone positioning has been used in the ICU to
  improve gas exchange in ARDS and improve Pa/FiO2
  in patients on mechanical ventilation and reduces
  cardiovascular comorbidities.

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Is Proning Use
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Awake proning
Prone Ventilation

• If Spo2 lt94 on Fio2 40
• By either venturi facemask or high flow nasal
  cannula
• 1. 30 to 120 mins prone
• 2. 30 to 120 mins left lateral
• 3. 30 to 120 mins right lateral
• 4. 30 to 120 mins upright
• Contraindicated
• In altered mental status and hemodynamic
  instability, pregnancy , vomiting Before proning
  increase fio2 to 100 percent for five minutes.

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Program setting

• Inpatient
• Outpatient
• Home based rehabilitation
• Multidisciplinary team approach is necessary.
• It requires a coordinated work of-
• Pulmonologist
• Physiotherapist
• Dietician
• Psychologist

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Lower Limb, Upper Limb and Chest Exercise
Training given at Asthma Bhawan
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I feel my stamina has increased a lot. Earlier, I
had difficulty in breathing on walking. I could
walk for around 500m in a day. But now I walk
around 3.5km without feeling breathless.Patient
name Jyoti, 38F Diagnosis Post
COVID-19/DM
No. of sessions 7 day sessionsCTSS 18/25
Before
AfterFVC 58
676MWTSpO2 initial 92
97SpO2 final 96
96Distance 420m
562m
Patient experiences

• I feel much more energetic and less fatigued
  after pulmonary therapy exercises.
• Patient name Mr Pradeep Kumar, 64M
  
• Diagnosis Post COVID-19
  
  
• No. of sessions 7 day sessions (Feb-April)
• Before
  AfterFVC 67
  716MWTSpO2 initial 96
  96SpO2 final 91
  94Distance
  420m 546m

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My take on the PR story..

• In the months to years after this pandemic, the
  burden of disease may be large and PR will play a
  crucial role in the rehabilitation of patients
  with disability in relation to COVID-19.
• PR includes nutrition, airway, posture, clearance
  technique, oxygen supplementation, breathing
  exercises, stretching, manual therapy, and
  physical activity.
• Multidiscpinary team effort is needed for the
  successful completion of PR programme.

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Save this MIRACLE which we all call Earth

• Thank you