Pulmonary Rehabilitation Programme

Pulmonary Rehabilitation Programme RichardS

Eligibility, referral and assessment

Eligibility, referral and assessment
  1. Eligibility Criteria

People with tuberculosis need to be identified, assessed and referred to the pulmonary rehabilitation programme. The Medical officer at the PHC/Health and Wellness Centre or the chest clinics shall identify people affected with tuberculosis and on basis of the following to refer the candidate to the pulmonary rehabilitation programme.

Inclusion criteria

  • Patients who have dyspnoea or cough due to Tuberculosis
  • Patients with post TB fibrosis, pleural thickening, bronchiectasis, with fibro-cavitary lesions or with destroyed lungs diagnosed on basis of Radiology (X-Ray/ CT scan)
  • Reduced exercise tolerance
  • People with post tubercular obstructive airway disease diagnosed clinically or on spirometry
  • People on treatment needing support with issues like psychosocial support/ de-addiction/ alcoholism/ smoking cessation 

Exclusion criteria

  • People who are unable to walk or having locomotor issues
  • People who have unstable angina or have had recent myocardial infarction or having unstable heart diseases like 
  • People having difficulties following instructions due to cognitive or psychiatric impairments
  • People with uncontrolled Blood Pressures, Diabetes, liver diseases, low haemoglobin levels or low oxygen saturations (<80%).

Pulmonary rehabilitation programme will benefit individuals who have completed treatment for tuberculosis or are on treatment as per the above mentioned inclusion/exclusion criteria. These include:

 

  • Out-patients 
  •  Immobile or in-bed patients, where the pulmonary rehabilitation programme can be offered near the bedside
  • In-patients who can attend the pulmonary rehabilitation programme at the centre and come back post discharge to complete 3 months of the program

2. Referral for Pulmonary Rehabilitation 

The doctors at DR-TB center/ chest clinics/ peripheral health institutes should carefully evaluate every case of pulmonary TB completing treatment for the possibility of developing Post TB Lung Disease and then refer them to the pulmonary rehabilitation programme centre. The assessment should be conducted at the earliest and at the end of treatment. Basic examinations should be conducted with the aim to identify patients with sequelae at risk of deterioration and those likely to benefit from Pulmonary rehabilitation program. 

The following set of basic examinations is considered essential before referral to a pulmonary rehabilitation program: 

  • Clinical examination and brief medical history
  • Persistent symptoms
  • Dyspnoea/breathlessness
  • Disability of daily activities
  • Sputum examination: smear / culture 
  • Chest X-Ray
  • Spirometry
  • Six-minute walk test (6MWT)

3. Patient assessment at Pulmonary Rehabilitation Centre 

The patients will be enrolled on Pulmonary Rehabilitation Programs based on the clinician's referrals and indications for rehabilitation. Following this, they will be undergoing education and counselling regarding the importance of pulmonary rehabilitation and how it will affect their quality of life.

The patient card will be completely filled up with all the below mentioned. (patient card is depicted in Annex 4)

  • Detailed and complete medical history of the person to be recorded
  • Complete baseline clinical examination to be conducted 
  • Assessment of quality of life using St. George questionnaire (Annex 1)
  • Assessment of dyspnoea using modified MRC scale (Annex 2)
  • Height, weight, Body Mass Index
  • Hb% (Haemoglobin levels)
  • Blood sugar levels- Fasting & Post prandial
  • Pulmonary Function Test results
  • X-Ray chest PA view
  • Sputum for AFB
  • ECG
  • 6-minute walking test result with SpO2 levels (Annex 3)

Parameters

Methods of assessment

Impaired exercise capacity

Six-minute walking test (Annex 3)

Five repetitions sit to stand test

Impaired pulmonary function showing airflow obstruction or restriction or mixed abnormalities and bronchodilator response

Spirometry

Impaired quality of life

Modified Medical Research Council scale (Annex 2)

 

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Respiratory Therapy

Respiratory Therapy

After the enrolment there is a plan designed for the individual. This person-tailored nature of pulmonary rehabilitation, means that the desirable components of pulmonary rehabilitation should vary across individuals according to their needs suiting to their needs and in a manner most convenient to them. 

The rehabilitation sessions include breathing exercises, airway clearance techniques, thoracic mobility exercises, posture correction and incentive spirometry. It also includes teaching them energy conservation techniques such as planning, prioritising the activities, pacing, and use of proper body mechanics.

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Breathing and Exercise training

Breathing and Exercise training

Based on the number enrolled, it could be given in a group of 5 people. If there are 30 members enrolled, they may be divided into 6 groups of 5 each. 

  • Each group may be advised a pulmonary rehabilitation program for duration of 6-12 weeks.
  • There should be 3 supervised sessions per week
  • A warm up session of 5-10 minutes prior to the session and a cool down-stretching session 5 minutes’ post exercise session is recommended. 

a. Airway clearance techniques:

Choose the technique suitable for the subject among those available, based on respiratory capacity, mucus rheology, and patient preferences. 

  • 15–30 min one or more times/day.
  • Choose the duration of treatment based on chronicity
  • Suggest maintenance programme when needed

b. Breathing Exercises:

Teach the patients the mentioned techniques which will aid them in breathing in an efficient manner with all the reserves they are left with.

  • Pursed lip Breathing
  • Deep diaphragmatic Breathing
  • Incentive Spirometer
  • Postural Drainage Positions
  • Huffing/ Coughing Techniques 

     

c. Inspiratory muscle training:     

  • Load threshold devices are used with patient seated and using a nose clip. 
  • It is an interval training where 10 exercises sets are followed with 10 seconds break between each training 

 

 

d. Aerobic exercise:

Endurance training

Each person performs the following exercises in rotation 

  • Treadmill 
  • Arm ergometry
  • Walking
  • Stepping
  • Stationary cycling

Time duration for each exercise should be in bouts of 10 minutes each and the frequency should be minimum of 3 and up to 5 times a week for 4–8 weeks. The intensity to be set according to the perceived dyspnoea.

 

e. Strength training:

The following sets of exercises should be carried out in sets of 2-3 with 6-12  repetitions. The frequency of the regimen be 3 days in a week with the duration of session being 20-30 minutes. Intensity set according to perceived muscles fatigue. Free weights (dumbbells and ankle-brace) can be used.

Upper limb:

  • Shoulder forward flexion
  • Shoulder abduction
  • Overhead shoulder press
  • Biceps curl
  • Overhead triceps extension
  • Scapular retraction

                         Lower limb:

  • Wall squats
  • Lunges
  • Hip abduction
  • Hip extension
  • Dynamic quads
  • Calf raises
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Yoga training

Yoga training

The pulmonary rehabilitation program should incorporate the yoga session as per the individualized plan wherever there is availability of trained yoga teachers/ instructors under their expert guidance.

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Pharmacological management of comorbidities

Pharmacological management of comorbidities

Some of the entities to be kept in consideration during the program or while preparing the discharge/ follow up card are as follows:

  • Desaturation:        Start oxygen by nasal cannula/ mask

Use oxymizers if patient is on oxygen therapy

  • Breathlessness:     Nebulize with Bronchodilators/ Inhaled steroids

Intravenous injection of Hydrocortisone/ Deriphyllin

  • Haemoptysis:        Intravenous injection of Tranexamic acid

Nebulization with Adrenaline

  • Acute cardiac event/ unconsciousness: Perform CPR, call for an ambulance with medical assistance and shift to hospital
  • Diabetes: Check for their regular medicine adherence/ check for control/   educate on importance of control
  • Hypertension: Check for their regular medicine adherence/ check for control/ educate on importance of control
  • Hypothyroidism: Check for their regular medicine adherence/ check for control/ educate on importance of control
  • Patient on regular use of INHALERS with inhaled steroids/ bronchodilators, check for the techniques
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Nutritional support

Nutritional support

For every person enrolled in the pulmonary rehabilitation program

  • Nutritional assessment should be carried out.
  • Evaluate and address malnutrition by education on a balanced diet rich in nutrients.
  • Monitor weight and dietary intake regularly.
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Psychological support

Psychological support

For every person enrolled in the pulmonary rehabilitation program

  • Psychological assessment to be carried out
  • Psychological support to be provided through personal counselling, counselling of family members.
  • Smoking & Alcohol cessation linkages and services to be strengthened 
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