Pulmonary (Respiratory) Rehabilitation

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It is an important part of treatment in patients with chronic lung disease. It reduces and controls symptoms, increases functional capacity and reduces health expenditures of patients. The first studies started in the 1970s. With its acceptance in the 1990s, it has become a part of standard treatment in patients with chronic lung disease.

What Is Pulmonary Rehabilitation?

It is a multidisciplinary and comprehensive method that systematically uses evidence-based diagnosis and treatment options in order for the individual with clinical or physiologically determined chronic respiratory disease-related inability or disability to optimally maintain personal daily functions and health-related quality of life.

It is a multidisciplinary approach. It is necessary to plan individually. It is aimed to increase physical and social functions, relieve symptoms, increase functional capacity and improve quality of life. It is a part of care in patients with symptomatic lung disease.

What Are The Components Of Pulmonary Rehabilitation?

  • In patients, the following are performed: initial assessment, education, exercise training, psychosocial support, nutritional support, and final assessment. This program is a 6- to 12-week program, which is applied in sessions lasting 2 to 4 hours, 3 days a week.

The most prominent pathophysiological finding in chronic obstructive pulmonary disease is expiratory airflow limitation and air trapping, which are exacerbated with effort. There is rapid shallow breathing characterized by increased respiratory rate and respiratory impulse, and decreased tidal volume, which results in shortness of breath and decreased activity level.

As a result of respiratory disease, the following may occur:

  • Peripheral muscle dysfunction
  • Respiratory muscle dysfunction
  • Nutritional disorders
  • Cardiac disorders
  • Musculoskeletal disorders
  • Sensory defects
  • Psychosocial dysfunction
  • Conditioning disorders
  • Malnutrition
  • Effects of hypoxemia
  • Steroid myopathy
  • Hyperinflation
  • Diaphragmatic fatigue
  • Anxiety, guilt, sleep problems
  • Pulmonary rehabilitation does not have a direct effect on airflow limitation. There is a decrease in lactate production and ventilation at a certain workload. Improvement in peripheral muscle dysfunction and a decrease in dynamic hyperinflation during exercise, a decrease in dyspnea, and an increase in exercise capacity are achieved.


  • The goals of pulmonary rehabilitation are to reduce respiratory workload, improve pulmonary function, correct arterial blood gases, reduce dyspnea, increase energy efficiency, correct impaired nutrition, improve exercise performance and the level of daily living activities, improve mood, reduce health-related costs, and prolong life.


  • Pulmonary rehabilitation can be done inpatient or outpatient. The decision of whether to do it in the hospital or community-based is based on the severity of the disease, the patient’s age and preference, comorbidities, environmental conditions, rehabilitation center distance, additional treatments received, and the patient’s physical, functional, and psychosocial status.


  • The evaluation of patients includes medical history, physical examination, baseline chest X-ray, resting ECG, pulmonary function tests, arterial blood gas analysis, health status and functional assessment tests, and exercise tests.

Who Is Pulmonary Rehabilitation Performed?

  • COPD
  • Asthma
  • Chest wall diseases
  • Lung disease after ARDS
  • Lung cancer
  • Some neuromuscular diseases
  • Perioperative conditions (thoracic, abdominal surgery etc.)
  • Postpolio syndrome
  • Before and after lung transplantation
  • Before and after lung volume reduction surgery

What Should Be Considered In Patient Selection For Pulmonary Rehabilitation?

People with symptomatic chronic lung disease who are in a stable condition, have respiratory distress (dyspnoea), have reduced exercise tolerance, have limitations in activities of daily living, are willing to participate in the programme and do not have a disease that prevents them from participating in the pulmonary rehabilitation programme should be preferred.

Who Is Not Suitable For Pulmonary Rehabilitation?

Unstable comorbidities that may jeopardise the health of patients during exercise, severe pulmonary hypertension, angina, recent heart attack, aortic valve disease, congestive heart failure, diabetes, patients who cannot exercise (such as orthopedic injury), conditions that may prevent patients from receiving rehabilitation (such as cognitive / psychiatric impairment, advanced arthritis, difficulty in learning, unwillingness to participate) are barriers to participation.

Which Exercise Tests Are Performed Before Pulmonary Rehabilitation?

  • Cardiopulmonary stepped exercise test
  • Single digit endurance test
  • 6/12 min walk test
  • Shuttle test

What Is The VO₂ Max Concept?

Maximal oxygen consumption rate. It is the unit of measurement of aerobic capacity. The open circuit spirometry system covers the measurement of O₂ and CO₂ in the collected breathing air. The metabolic analysis of the expired gases is performed by applying a gradually increasing exercise test of increasing intensity using predetermined “exercise test protocols”. Measurement is performed by direct or indirect method.

What Is The 6 Minute Walk Test?

It is the easiest and most widely used test among pulmonary tests. No special equipment is required. There should be a corridor at least 30 metres long and not normally used for the patient to walk comfortably. A stopwatch can be used during the measurement. It should be ensured that six minutes are kept exactly. Pulse oximetry can be used to monitor hypoxia during exercise. But it does not have to be in the test standard.

What Are The Components Of Pulmonary Rehabilitation?

  • Patient education and smoking cessation
  • Nutritional assessment and support
  • Psychosocial support
  • Long-term oxygen therapy
  • Mechanical ventilation
  • Occupational therapy
  • Bronchial hygiene techniques
  • Controlled breathing techniques
  • Exercise training

What Should Be Emphasised In Education?

Patients are advised to conserve their energy and to simplify the work. Information about medical treatment and other therapies should be given. Nutritional recommendations and information about the prognosis of the disease should be provided. The physical and psychosocial changes that occur in chronic diseases should be better understood. With education, the patient is made aware and becomes more skilful in self-treatment.

What Would You Like To Say About Long Term Oxygen Therapy?

When PaO2 <7.3 kPa (55 mmHg) or SaO₂ <90%, it is recommended to monitor with pulse oximetry so that PaO₂ is at least above 8.5 kPa (SaO₂ >92%). Pulmonary patients without hypoxaemia at rest may often show marked arterial oxygen desaturation (SaO₂ <4% or a fall of more than 88-90%) during ambulation. Ambulatory support is oxygen therapy.

What Are Bronchial Hygiene Techniques?

  • Forced expiration techniques
  • Cycle of active breathing techniques
  • Autogenic drainage
  • Positive expiratory pressure application
  • Flutter breathing
  • Postural drainage
  • Percussion and vibration
  • Incentive spirometry

What Is Positive Expiratory Pressure Application?

Expiration against a resistance prevents airway collapse and improves collateral ventilation. PEB increases functional residual capacity. It reduces resistance in collateral and small airways. It is applied with a special equipment. Expiratory pressure is maintained at a pressure of 10-20 cm H2O during expiration.


Applying a manoeuvre similar to cardiopulmonary resuscitation with a frequency of 10-15 Hz on the area to be drained during expiration

What Is Postural Drainage?

The aim of postural drainage is to increase the excretion of mucus from the airways. It is provided by giving gravity-assisted positions. In order to utilise gravity to facilitate the transport of mucus to the central airways, the patient should be placed with the main bronchus in the most vertical position. Bronchodilators should be used 10-20 minutes before postural drainage.

Since secretion accumulation is mostly nocturnal, the first one should be performed in the morning before breakfast and 3-4 times a day, each special position starting from 5 minutes and extending to 15 minutes. It should be performed at least two hours after meals and postural drainage should be followed by controlled coughing or huffing techniques.

What Is Flutter Breathing?

A fluctuating expiratory pressure and airflow are created in the mouth to facilitate the clearance of mucus. Special equipment is required.

Incentive Spirometry

Long, slow and deep breathing is achieved with the help of a device. It teaches the patient how to inflate and maintain the lungs by providing visual feedback. With the device, a deep and slow breath is taken up to a predetermined level, the air held inside for 3 seconds is blown out by removing the mouthpiece. After 10-15 repetitions, sputum is removed with a controlled cough manoeuvre.

What Are Controlled Breathing Techniques?

  • Puckered lip breathing
  • Segmental respiration
  • Relaxation exercises
  • Diaphragmatic breathing
  • Slow and deep breathing
  • Air dialling technique
  • Frog respiration
  • Trendelenburg and forward bending postures
  • Abdominal girdle

What Are The Major Factors Causing Exercise Restriction In The Patient Candidate For Pulmonary Rehabilitation?

  • 1-Cardiovascular causes
  • 2-Pulmonary causes
  • 3-Peripheral causes
  • 4-Others (such as lack of fitness, lack of motivation…)

What Are The Mechanisms Of Exercise Restriction In The Patient Candidate For Pulmonary Rehabilitation?

  • Ventilatory restriction (decreased respiratory reserve): dyspnoea, hypoxaemia, lactic acidosis and hypoventilation
  • Ventilatory failure (there is dynamic hyperinflation): airway collapse, tachypnoea, hypoventilation
  • Gas exchange disorders (hypoxaemia or hypercapnia): desaturation and respiratory acidosis
  • Cardiovascular restriction: angina, hypertension and arrhythmia
  • Deconditioning: early lactic acidosis
  • Symptomatic restriction: dyspnoea, anxiety and fear

What Is Taken Into Account In Determining The Intensity Of Exercise Programmes?

  • Heart rate: It has been suggested that using heart rate as a physiological target in a patient with COPD is not very accurate (the problem is ventilatory restriction and gas exchange disorders)
  • Peak Workload and VO₂ : Maximum symptom limited exercise test
  • Severity of symptoms: The score obtained with the Borg scale is important in determining exercise intensity

Exercise training includes aerobic exercises, lower and upper limb and shoulder girdle exercises, respiratory muscle exercises, neuromuscular electrical stimulation and strengthening training. An individual exercise programme should be designed and lower limb exercises should be included in every exercise programme (walking on a treadmill or stationary bicycle). Individual organisation of the duration, frequency and intensity of training is recommended. Exercise training should be performed at the highest level that the patient can perform. At least 20-30 min/3 sessions per week should be planned. It should be started at an intensity of 60-70 per cent of maximum capacity. It can be done continuously/intermittently. Severe chest and leg pain during exercise prevents exercise until the cause is identified. 12-way ECG monitoring during exercise is important to rule out coronary diseases. Unstable angina or congestive heart failure are contraindications for exercise.

“Saturation monitoring: desaturation detection” is important.

  • Especially if SaO² is <88% or decreases below 88% during exercise, supplemental O² therapy should be recommended during exercise. Currently, there is no data on the benefit of supportive O² in nonhypoxaemic patients. In severe hypoxaemia that persists despite supportive O² or in desaturations that develop more than 20%, exercise

Weighted upper limb training Weight (500-750 g): lift the weight to shoulder level ( vertically and obliquely) for two minutes, equal to the respiratory frequency, rest for 2 minutes. This chain is repeated 7-8 times (28-32 min). The weight is increased by 250 gr after every 5 exercise sessions. 24 sessions (8 weeks) is recommended.

What Are Respiratory Muscle Exercises?

  • Voluntary isocapnic hyperpnoea: Minute ventilation at as high a level as possible for 10-15 min twice a day
  • Inspiratory resistive loading: The patient is asked to breathe in and out through inspiratory openings of progressively narrower diameter
  • Inspiratory threshold loading: Training is performed with a threshold loading device that allows inspiration only after the mouth pressure reaches a certain value.

Why Is Psychosocial Support Necessary?

Patients develop anxiety and depression, feelings of loneliness, anger, fear and eventually sedentary lifestyle and avoidance of society. Therefore, it is important to teach stress reduction techniques.

What Does Nutritional Assessment And Support Include?

Weight loss and loss of muscle mass are characteristic in these patients. The prognosis is worse in patients with low body mass. It is requested to eat little and often, to feed with small bites and not to fill the mouth too much. It is recommended to increase the supplementary oxygen given during feeding. It is recommended to provide carbohydrate-poor nutrition and non-protein calorie intake.

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