Respiratory Rehabilitation

Written by Pedro Toscano

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What is Respiratory Rehabilitation?

Respiratory rehabilitation is an evidence-based, well established and widespread therapeutic intervention. The goal of respiratory rehabilitation is to reduce a patient’s symptoms, including breathlessness and improve their functionality and quality of life.

Chronic respiratory diseases, such as COPD (chronic obstructive pulmonary disease), asthma (severe) or pulmonary fibrosis, can have significant negative consequences for patients. These diseases can particularly cause breathing difficulties that in many cases can gradually worsen over time. This can lead to limitations on daily activities, social and professional life, and impact on quality of life.
Respiratory rehab is a pliable term that generally refers to a rehabilitation programme that is prescribed as a complement or following medical treatments (such as medication, inhalers, oxygen therapy, etc). It is planned as part of the general care decided upon by a multidisciplinary team in hospital that typically comprises Physiotherapist, Occupational Therapist, Respiratory Nurse, Physician, Psychologist and Social Worker.

Respiratory rehab can also take place outside the hospital (after referral or medical clearance from the patient’s GP or current consultant) in an out-patient clinic, institution, or at a patient’s homes. The rehab is usually conducted by a Physiotherapist, which is why it is also often called Respiratory Physiotherapy (Rodrigues et al., 2020).

A respiratory rehab programme usually makes use of different “tools” that can include, but are not limited to, patient advice and education, strategies for conserving energy, monitoring of medication, inhalers or oxygen use, personalised exercise programme (pulmonary rehab), breathing techniques and exercises and occasionally manual techniques that can help increase lung volume temporarily or clear secretions (mucus or sputum).

Rehabilitation does not reverse lung damage, but it modifies the disability that results from it by concentrating on the symptoms. In this way, the rehabilitation does not focus on the disease process (although it has to take it into account), but its main focus is on the various physical and psychological repercussions of the chronic disease.

By means of therapeutic interventions each programme is tailored to the individuals specific needs. The main goals of respiratory rehab are to improve the patient’s functionality and endurance to physical and daily activities, reduce or help manage their symptoms, improve physical and mental wellbeing, minimise future complications, promote long term health, and improve patient’s quality of life (Rodrigues et al., 2020, Spruit et al., 2013).

Is Pulmonary Rehab the same as Respiratory Rehab?

Patients with chronic respiratory disability are commonly prescribed an individual exercise programme as part of their respiratory rehab programme.

The term ‘pulmonary rehab’ is specifically used to describe the exercise component of the respiratory rehab – the exercise plan. The exercise plan is tailored to each individual’s symptoms and needs. It usually involves aerobic exercise (such as walking, cycling, swimming) that works on improving endurance, as well as resistance training, that works on both strength and endurance.

The benefits of physical exercise for the cardiorespiratory system and the body in general are many and well known. A gradual, supervised and progressive exercise plan enables patients with chronic respiratory diseases to improve their physical performance and endurance during activities, with less fatigue, less shortness of breath, more autonomy and more independence (McCarthy et al., 2015, Rodrigues et al., 2020, Vogiatzis et al., 2016).

The exercise sessions or pulmonary rehab sessions, are commonly performed in groups (6 to 10 participants) that are stratified for mild, moderate and severe disease. There can also be individual, one-to-one sessions, as is the case for example in a patient’s home, or when it is desirable to minimise aerosol/ respiratory droplets production.

Patients can benefit regardless of the severity of their disease, age and fitness levels, although there are some contra-indications as it is the case with any kind of exercise programme. These can include acute disease, symptomatic or uncontrolled cardiovascular disease, recent heart attack, metastatic cancer, among others (Hough., 2001, McCarthy et al., 2015, Pryor and Prasad., 2008, Spruit et al., 2013, Vogiatzis et al., 2016).

Before commencing the exercise programme it is likely that the Physiotherapist will perform exercise tolerance tests as part of a more general assessment of each patient’s impairments, symptoms, needs and goals. These tests usually assess how far a person can walk, how many step ups and downs, how many times a person can sit and stand in a set amount of time. The Physiotherapist will monitor the patient’s breathlessness, oxygen levels (pulse oximeter), heart rate and blood pressure, before, during and after the patient performs the tests.

The results of these tests will give an accurate measure of the patient’s current endurance and tolerance levels, as well as an indication of progress as the tests are repeated at regular time intervals.
The monitoring process will continue throughout the exercise sessions to make sure patients are not exercising beyond their individual safety level. Patients are encouraged and taught how to monitor their own oxygen levels, heart rate and blood pressure, when performing physical activities on their own (gardening, DIY, etc) (Hough., 2001, McCarthy et al., 2015, Pryor and Prasad., 2008, Spruit et al., 2013, Vogiatzis et al., 2016).

How do breathing exercises help?

Breathing exercises or breathing techniques are another tool that is also utilised as part of a respiratory rehab programme or respiratory Physio. They can be used in isolation, however, just like exercise, they are more effective in tackling chronic respiratory disabilities when used in conjunction with other components of respiratory rehab/Physio. This can include advice & education, pain relief and mobilisation techniques. It is not sufficient to intervene in a process as personal as breathing without attention to the person as whole.

There are many things that influence how we breathe besides the obvious exercise increase – from our emotions to our diet and our health. Our breathing can become faster, or slower, shallower, or deeper, more chaotic, or more regular. This in turn has an influence on how fast our heart beats, how much oxygen we take, among other chemical changes which will have an effect on our feelings. For example when we notice our breathing and heartbeat are going faster without an apparent reason, this might make us feel nervous, and stress itself will increase how fast we breathe and how fast our heart beats in a vicious cycle of breathlessness and anxiety (Hough., 2001, Ma et al., 2017, Pryor and Prasad., 2008).

During respiratory rehab sessions, patients can learn how to breathe better and more effortlessly. Learning how to utilise breathing techniques to manage exacerbations on some of their symptoms such as cough, breathlessness and dizziness. People who suffer from frequent coughing can learn how to use their cough in a more effective manner as well as different breathing exercises that help in keeping the airways clear.

In many cases patients also improve their self-management and knowledge of what to do when their disease exacerbates by learning how to hydrate and clean their airways from excessive mucus production, how to pace their activities and conserve their energy, and how to utilise their prescribed medication and/or inhalers if they are unsure. Having good self-management strategies will probably lead to less serious exacerbations and less likelihood of having to be admitted to hospital (Hough., 2001, Pryor and Prasad., 2008, McCarthy et al., 2015).

References

Hough, A., 2001. Physiotherapy in respiratory care: An evidence-based approach to respiratory and cardiac management. Nelson Thornes.

Ma, X., Yue, Z.Q., Gong, Z.Q., Zhang, H., Duan, N.Y., Shi, Y.T., Wei, G.X. and Li, Y.F., 2017. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in psychology, 8, p.874.

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E. and Lacasse, Y., 2015. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane database of systematic reviews, (2).

Pryor, J.A. and Prasad, A.S., 2008. Physiotherapy for respiratory and cardiac problems: adults and paediatrics. Elsevier Health Sciences.

Rodrigues, A., Muñoz Castro, G., Jácome, C., Langer, D., Parry, S. and Burtin, C., 2020. Current developments and future directions in respiratory physiotherapy. European Respiratory Review, 29(158), p.200264.

Spruit, M.A., Singh, S.J., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., Hill, K., Holland, A.E., Lareau, S.C., Man, W.D.C. and Pitta, F., 2013. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American journal of respiratory and critical care medicine, 188(8), pp.e13-e64.

Vogiatzis, I., Rochester, C.L., Spruit, M.A., Troosters, T. and Clini, E.M., 2016. Increasing implementation and delivery of pulmonary rehabilitation: key messages from the new ATS/ERS policy statement.

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