Pulmonary rehabilitation (PR) is a comprehensive intervention for patients with chronic respiratory diseases to reduce symptoms, optimize function, and increase quality of life. It includes education, exercise training, nutritional counseling, and psychological support. Guidelines recommend PR programs include 20-30 sessions over 6-12 weeks with exercise 3 times per week. Exercise training, including endurance, strength, and respiratory muscle training provides benefits like increased exercise tolerance and quality of life. Nutritional interventions aim to address weight loss and malnutrition common in respiratory disease. Outcome is assessed using measures of symptoms, exercise capacity, quality of life, and nutritional status.

1. By
Riham Hazem Raafat
Lecturer of Chest Diseases
Ainshams University

2. Learning Objectives
• Definition of PR
• Benefits of PR
• Components of PR
• Selectivity of patients fit for PR
• Different programs of exercise in PR
• Nutritional plan in PR
• Different guidelines’ recommendations

3. DISEASE
IMPAIRMENT
DISABILITY
HANDICAP
TREATMENT
REHABILITATION
REHABILITATION

4. Spiral of Disability

5. • Evidence-based, multidisciplinary, and comprehensive
intervention for patients with chronic respiratory
diseases who are symptomatic and often have
decreased daily life activities
• Integrated into the individualized treatment of the
patient, pulmonary rehabilitation is designed to reduce
symptoms, optimize functional status, increase
participation, reduce health care costs through
stabilizing or reversing systemic manifestations of the
disease, and increase activities & QOL
ATS – ERS Definition

6. General
exercise
training

7. Pathophysiology

8. • Peripheral muscle dysfunction
• Respiratory muscle dysfunction
• Nutritional abnormalities
• Cardiac impairment
• Skeletal disease
• Sensory defects
• Psychosocial dysfunction
Consequences of
Chronic Respiratory
Disease • Deconditioning
•Malnutrition
•Effects of hypoxemia
•Steroid myopathy or
ICU neuropathy
•Hyperinflation
•Diaphragmatic fatigue
•Psychosocial dysfunction from
anxiety, guilt, dependency and
sleep disturbances
Mechanisms of these
Morbidities

9. Benefits of Pulmonary Rehabilitation
Pulmonary rehabilitation does not reverse nor have any direct effect
on the primary respiratory pathophysiology, yet it has proven to
improve the following:

10. Obstructive Diseases: COPD patients at all stages of
disease appear to benefit from exercise training
programs improving with respect to both exercise
tolerance and symptoms of dyspnea and fatigue ((GOLDGOLD))
Restrictive Diseases
Interstitial
Chest Wall
Neuromuscular
Other Diseases
Patient Selection

11. • Patients with severe orthopedic or neurological disorders
limiting their mobility
• Severe pulmonary arterial hypertension
• Exercise induced syncope
• Unstable angina or recent MI
• Refractory fatigue
• Inability to learn, psychiatric instability and disruptive
behavior
Exclusion Criteria

12.  Control of symptoms of cough and fatigue:
 Real time eval.: MRC breathlessness & Borg dyspnea scale
 Recall of symptoms
 Performance evaluation: Ability to do ADL
 Directly observed or self reported + PFTs, ABG or Oximetry
 Exercise tolerance:
 6 minutes walking test
 Cardiopulmonary exercise testing
 Quality of life: (specific or non-specific)
 Chronic respiratory disease questionnaire & SGRQs
 SF- 36
 Assessment of respiratory and peripheral muscle strength
 Nutritional assessment
 History, Laboratory, Anthropometric, Calorimetry (D&ID)
Baseline Evaluation

13. • Outpatient
• Inpatient
• Home
Choice varies depending on:
- Distance to program
- Insurance payer coverage
- Patient preference
- Physical, functional, psychosocial status of patient
Setting for Pulmonary Rehabilitation

14. •Breathing Strategies
•Normal Lung Function and
Pathophysiology of Lung Disease
•Proper Use of Medications, including Oxygen
•Bronchial Hygiene Techniques
•Benefits of Exercise and Maintaining Physical Activities
•Energy Conservation & Work Simplification Techniques
•Eating Right
1- Education

15. • Irritant Avoidance, including Smoking Cessation
• Prevention and Early Treatment of Respiratory
Exacerbations
• Indications for Calling the Health Care Provider
• Leisure, Travel, and Sexuality
• Coping with Chronic Lung Disease and End-of-Life
Planning
• Anxiety and Panic Control, including Relaxation
Techniques and Stress Management

16. 2- Exercise training
Pathophysiological abnormality Benefits of exercise training
Decreased lean body mass (N: 60-90%) Increases fat free mass
Decreased Type 1 fibers Normalizes proportion
Decreased cross sectional area of muscle
fibers
Increases
Decreased capillary contacts to muscle
fibers
Increases
Decreased capacity of oxidative
enzymes
Increases
Increased inflammation No effect
Increased apoptotic markers No effect
Reduced glutathione levels Increases
Lower intracellular pH, increased lactate
levels and rapid fall in pH on exercise
Normalization of decline in
pH

17. Components of exercise training:
• Lower extremity exercises
• Arm exercises
• Ventilatory muscle training
Types of exercise:
• Endurance or aerobic
• Strength or resistance

18. • Walking
• Treadmill
• Stationary bicycle
• Stair climbing
• Sit & Stand
Lower extremity exercise

19. Benefits in COPD
• Increased work capability as assessed by pre & post PR
incremental treadmill protocol or 6 min walking distance
• 40 – 102% increase in endurance of maximal work rate
• Significant improvement in subjective assessment using
Borg dyspnea scale
• No changes in hemodynamics during exercise

20. • Arm cycle ergometer
• Unsupported arm lifting
• Lifting weights
Arm exercise training

21. Benefits in COPD
• Has the potential to improve arm exercise performance
& capacity by decreasing ventilatory & metabolic
demand during arm work (measured by Vo2), and by
improving arm endurance.
• Arm training improves the ventilatory contribution of
those muscles by increasing shoulder girdle muscle
strength.
• No significant effect on outcomes, such as functional
status and performance when arm training used alone.

22. Strength exercises:
When strength exercise was added to standard exercise
protocol; led to:
greater increase in muscle strength and muscle mass
(FFM)  increased mid-thigh circumference
But NO additional benefit in:
 Exercise capacity as assessed by 6MWD or CPET
 HRQOL
 Physiological parameters of heart rate or blood lactate
levels

23. Resistive non-targeted IMT:
Patient breaths through hand held
device with which resistance to
flow can be increased gradually.
Pressure Threshold IMT:
Patient breaths through a device
equipped with a valve which opens
at a given pressure.
• Difficult to standardize the load
• Patients may hypoventilate
• Leads to increased Pulmonary
Arterial Pressure and fall in
oxygen tension
• Easily quantitated and
standardized
Ventilatory muscle training
*30 breath twice daily, intensity 50% of Pimax, inc. 5% load/wk. for 6wks

25. • Voluntary Isocapnic Hyperventilation (VIH):
Endurance technique; patients are asked to breathe at the highest
rate they can manage for 15 to 30 minutes. Hypocapnia and its
accompanying symptoms are prevented by adding CO2 to the
inspired air or by requiring partial rebreathing of expired air.
Can improve maximum voluntary ventilation (MVV) in COPD.

26. • Pursed Lip Breathing – shifts breathing pattern and
inhibits dynamic airway collapse. (2s inh, 4s exh)
• Posture techniques – forward leaning reduces
respiratory effort, elevating depressed diaphragm by
shifting abdominal contents.
• Diaphragm Breathing – Some patients with extreme
air trapping and hyperinflation have increased WOB
with this technique
• Postural Draining – valuable in patients who produce
more than 30cc/24 hours - Coughing techniques
Chest Physical Therapy & Breathing
Retraining

27. Pursed Lip Diaphragmatic
Breathing

28. • Postural drainage
• Percussion
• Directed cough: as Forced expiratory technique (huffing:
small long (LL) or big short huff (UL) in cycle; 10 mins twice /d)
• Active cycle of breathing (breathing control (hands on abd.),
deep breathing exercises e’ breath hold (ribs) & huffing +/-
manual technique)
• Autogenic drainage (self drainage: unstick, collect, evacuate)
• Positive expiratory pressure (behind mucus to push)
• Incentive Spirometry
Bronchial Hygiene Techniques
Can be associated with others

29. Vibratory PEP
Flutter device
Acapella

30. • A minimum of 20 sessions should be given (6-12 wks)
• At least three times per week
• Twice weekly supervised plus one unsupervised home
session may also be acceptable.
• Once weekly sessions seem to be insufficient
• Each session to last 30 minutes (10-45)
• High-intensity exercise (50-60% of maximal work rate
or peak Vo2) produces greater physiologic benefit and
should be encouraged; however, low-intensity training
is also effective for those patients who cannot achieve
this level of intensity (ATS-ERS)
What do Guidelines Say?

31. • Both upper & lower extremity training should be utilized
• Lower extremity exercises like treadmill and stationary
bicycle ergometer & Arm exercises like lifting weights
and arm cycle ergometer are recommended
• The combination of endurance and strength training
generally has multiple beneficial effects and is well
tolerated; strength training would be particularly
indicated for patients with significant muscle atrophy
• Respiratory muscle training could be considered as
adjunctive therapy, primarily in patients with suspected
or proven respiratory muscle weakness (ATS/ERS)

32. • The minimum length of an effective rehabilitation
program is 6 weeks.
• Daily to weekly sessions
• Duration of 10 minutes to 45 minutes per session
• Intensity of 50% of VO2 max to maximum tolerated
• Endurance training can be accomplished through
continuous or interval exercise programs.
• The latter involve the patient doing the same total work
but divided into briefer periods of high-intensity
exercise, which is useful when performance is limited
by other comorbidities (GOLD)

33. • Optimal bronchodilator therapy should be given prior
to exercise training to enhance performance.
• Patients who are receiving long-term oxygen therapy
should have this continued during exercise training,
but may need increased flow rates.
• Oxygen supplementation during pulmonary
rehabilitation, regardless of whether or not oxygen
desaturation during exercise occurs, often allows for
higher training intensity and/or reduced symptoms in
the research setting. (ATS/ERS)
Additional considerations:

34. may be an adjunctive therapy for patients with severe
chronic respiratory disease who are bed bound or
suffering from extreme skeletal muscle weakness.
• Non invasive mechanical ventilation: Because
NPPV is a very difficult and labor-intensive
intervention, it should be used only in those with
demonstrated benefit from this therapy (ATS/ERS)
• Neuromuscular electrical stimulation (NMES):

35. Why intervene?
•High prevalence and association with morbidity and
mortality
•Higher caloric requirements from exercise training in
pulmonary rehabilitation, which may further aggravate
these abnormalities (without supplementation)
•Enhanced benefits, which will result from structured
exercise training.
3- Nutritional Interventions

36. Body composition abnormalities:
↑ ACTIVITY RELATED
ENERGY EXPENDITURE
HYPERMETABOLIC
STATE
DECREASED
INTAKE
IMPAIRMENT OF ENERGY
BALANCE
IMBALANCE IN PROTEIN
SYNTHESIS AND BREAKDOWN
LOSS OF FAT
LOSS OF WEIGHT: BMI <21
10% WEIGHT LOSS IN 6 MONTHS
5% WEIGHT LOSS IN 1 MONTH
LOSS OF FFM
ANTHROPOMETRY
BIOIMPEDANCE
ANALYSIS
DEXA
Lab. Investigations
CALORIC
SUPPLEMENTS
PROTEIN
SUPPLEMENT
STRENGTH
EXERCISE
ANABOLIC
STEROIDS
GROW
TH
HORM
ONE
INTERVENTIONS

37. Should be considered if :
•BMI less than 21 kg/m2
(2/3 pts referred to PR, 1/3 outpatients
are underweight and have greater impairment in HRQoL, increased
mortality independent on degree of obstruction)
•Involuntary weight loss of >10% during the last 6 months
or more than 5% in the past month (can’t depend in edema)
•Depletion in FFM or lean body mass (make QoL worse and
less tolerant to exercise even when normal weight)
Nutritional Supplementation

38. • Energy dense foods, well distributed during the day
• No evidence of advantage of high fat diet (pulmocare:
high fat low CHO formula  decrease Co2 retention)
• Patients experience less dyspnea after liquid
carbohydrate rich supplement than fat rich supplement.
(probably dt delayed gastric emptying  distention)
• Daily protein intake should be 1.5 gm/kg for positive
balance
• Antioxidants like vitamin C, E .. Also Vitamin D
Nutritional supplementation

39. • High-calorie snacks- creamy, rich puddings, crackers
with peanut butter, dried fruits and nuts.
• Beverages- milk-shakes, regular milk and high-calorie
fruit juices
• Breads and Cereals
• Pep up Your Protein- milk or soy protein powder to
mashed potatoes, gravies, soups and hot cereal
• Choose High-Calorie Fruits- bananas, mango, dates,
dried apples or apricots instead of apples, watermelon
• Remember Your Vegetables potatoes, beets, corn,
peas, carrots
• Healthy, Unsaturated Fats
• Soups and Salads
Small Frequent Meals
(decrease metabolic & ventilatory effort, loss of appetite)

40. Physiological intervention: Strength exercise
•Addition of strength training lead to increase in strength
and mid thigh circumference (measured by CT)
Pharmacological intervention :
- Anabolic steroids
•Anabolic steroids
•Nandrolone decanoate - 50 mg for male; 25 mg for
females; 2 Weekly 4 doses
•Anabolic therapy alone increases muscle mass but not
exercise capacity
Nutritional Interventions

41. - Growth hormone
•rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg &
1gm protein/kg per day has shown to increase fat free mass
•But does not improve muscle strength or exercise
tolerance (hand grip and maximal exercise) and no change
in well being of the patient.

42. - Testosterone
•Testosterone 100 mg weekly for ten weeks in men with
low testosterone levels 320 ng/ml showed weight gain of
2.3 kg
•Addition of exercise to testosterone has augmented weight
gain to 3.3 kg
•Physiological consequences and long term effects not
studied

43. INTERVENTION WEIGHT
GAIN
FFM GAIN EXERCISE
CAPACITY
CALORIC SUPP. + - -
CALORIC
SUPPLEMENTATION +
EXERCISE TRAINING
++ + +
STRENGTH EXERCISE - + -
ANABOLIC STEROIDS ++ ++ -
ANABOLIC STEROIDS +
EXERCISE
++ +++ ?

44. • Increased calorie intake is best accompanied by exercise
regimes that have a nonspecific anabolic action
• Anabolic steroids in COPD patients with weight loss
increase body weight and lean body mass; but have little
or no effect on exercise capacity. (GOLD)
• Pulmonary rehabilitation programs should address body
composition abnormalities. Intervention may be in the
form of caloric, physiologic, pharmacologic or
combination therapy. (ATS/ERS STATEMENT)
What do Guidelines Say?

45. • Screening for anxiety and depression should be part of
the initial assessment.
• Mild or moderate levels of anxiety or depression
related to the disease process may improve with
pulmonary rehabilitation
• Patients with significant psychiatric disease should be
referred for appropriate professional care (ATS/ERS
STATEMENT)
4- Psychological considerations

46. 5- Outcome Assessment

47.  Control of symptoms of cough and fatigue:
 Real time eval.: MRC breathlessness & Borg dyspnea scale
 Recall of symptoms
 Performance evaluation: Ability to do ADL
 Directly observed or self reported
 Exercise tolerance:
 6 minute walking test
 Cardiopulmonary exercise testing
 Quality of life:
 Chronic respiratory disease questionnaire
 St Georges’s respiratory questionnaire
 SF- 36
 Assessment of respiratory and peripheral muscle strength
 Nutritional assessment
Outcome Evaluation

48. • Current guidelines does not comment on maintenance
& repeat rehabilitation
• Yearly repeat rehabilitation program had shown: Short
term benefits in the form of less frequent exacerbations
• But no long term physiological effects on exercise
tolerance, dyspnea & HRQL but in 6Ms begin loss of
benefits
6- Maintenance rehabilitation &
Repeat rehabilitation program

49. • Assess the patient with spirometry, saturation, 6MWT,
weight/FFMI by biometric impedance, and bone density
by sonography, AQ 20 and PHQ questionnaire
• Treatment of osteoporosis & dietary advice by the
physician
• Exercise training by the physician or a trained staff, or an
assistant at the time of enrolment for 30 minutes
• Exercise should simulate the patient’s home environment
• The endurance and strength training can be done by
walking/ cycling, walking uphill/climbing stairs and
straight leg raise, respectively
Pulmonary Rehabilitation in
Resource Poor Settings

50. • The exercise should be guided by his ability to tolerate
exercise and 6MWT with periods of rest if desired. The
speed and distance should be increased gradually
• The patient can be educated about breathing techniques
by the physician/assistant
• The patients should exercise twice in a day for 30
minutes for at least 5 to 6 days in a week
• The patient may be given a diary to maintain
• The patient may follow up once in a week or 15 days for
reinforcement/increment/supervision of exercises

54. 1. Recommendation: A program of exercise training of
the muscles of ambulation is recommended as a
mandatory component of pulmonary rehabilitation for
patients with COPD. 1A
2. Recommendation: Pulmonary rehabilitation improves
the symptom of dyspnea in patients with COPD. 1A
3. Recommendation: Pulmonary rehabilitation improves
health related QOL in patients with COPD. 1A
ACCP RECOMENDATIONS

55. 4. Recommendation: Pulmonary rehabilitation reduces the
number of hospital days and other measures of health-
care utilization in patients with COPD. 2B
5. Recommendation: Pulmonary rehabilitation is cost-
effective in patients with COPD. 2C
6. Statement: There is insufficient evidence to determine if
pulmonary rehabilitation improves survival in patients
with COPD. No recommendation is provided.
7. Recommendation: There are psychosocial benefits from
comprehensive pulmonary rehabilitation programs in
patients with COPD. 2B

56. 8. Recommendation: Six to 12 weeks of pulmonary
rehabilitation produces benefits in several outcomes
that decline gradually over 12 to 18 months. 1A..
Some benefits, such as health-related quality of life,
remain above control at 12 to 18 months. 1C
9. Recommendation: Longer pulmonary rehabilitation
programs (12 weeks) produce greater sustained
benefits than shorter programs. 2C
10.Recommendation: Maintenance strategies following
pulmonary rehabilitation have a modest effect on long-
term outcomes. 2C

57. 11.Recommendation: Lower-extremity exercise training at
higher exercise intensity produces greater physiologic
benefits than lower intensity training in patients with
COPD. 1B
12.Recommendation: Both low- and high intensity exercise
training produce clinical benefits for patients with
COPD. 1A
13.Recommendation: Addition of a strength training
component to a program of pulmonary rehabilitation
increases muscle strength and muscle mass. 1A
14.Recommendation: Current scientific evidence does not
support the routine use of anabolic agents in
pulmonary rehabilitation for patients with COPD. 2C

58. 15.Recommendation: Unsupported endurance training of
the upper extremities is beneficial in patients with
COPD and should be included in pulmonary
rehabilitation programs. 1A
16.Recommendation: Scientific evidence does not support
the routine use of inspiratory muscle training as an
essential component of pulmonary rehabilitation. 1B
17.Recommendation: Education should be an integral
component of pulmonary rehabilitation. Education
should include information on collaborative self-
management and prevention and treatment of
exacerbations. 1B
18.Recommendation: There is minimal evidence to
support the benefits of psychosocial interventions as a
single therapeutic modality. 2C

59. 19.Statement: Although no recommendation is provided
since scientific evidence is lacking, current practice and
expert opinion support the inclusion of psychosocial
interventions as a component of comprehensive
pulmonary rehabilitation programs for patients with
COPD
20.Recommendation: Supplemental oxygen should be
used during rehabilitative exercise training in patients
with severe exercise-induced hypoxemia. 1C
21.Recommendation: Administering supplemental oxygen
during high-intensity exercise programs in patients
without exercise-induced hypoxemia may improve
gains in exercise endurance. 2C

60. 22.Recommendation: As an adjunct to exercise training in
selected patients with severe COPD, noninvasive
ventilation produces modest additional improvements
in exercise performance. 2B
23.Statement: There is insufficient evidence to support the
routine use of nutritional supplementation in pulmonary
rehabilitation of patients with COPD. No recommendation
is provided.
24.Recommendations: Pulmonary rehabilitation is
beneficial for some patients with chronic respiratory
diseases (CRD) other than COPD. 1B
25.Statement: Although no recommendation is provided
expert opinion suggest that PR for pts with CRD other
than COPD should be modified to include ttt strategies
specific to individual diseases & pts in addition to ttt
strategies common to both COPD & non-COPD pts.