What Are the Different Pulmonary Rehabilitation Exercises?

Rehabilitation can improve the ability of movement and improve the quality of life of patients with progressive airflow limitation, severe breathing difficulties and little activity. It is an important treatment for patients with chronic obstructive pulmonary disease. It includes respiratory physiotherapy, muscle training, nutrition support, psychotherapy and education.

Gao Hua	(Deputy Chief Physician)	Department of Cardiology, Beijing Rehabilitation Center
Zhang Jianxiu	(Attending physician)	Department of Cardiology, Beijing Rehabilitation Center
Zhang Zhenying	(Attending physician)	Department of Cardiology, Beijing Rehabilitation Center

Introduction to Rehabilitation of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common disease that can be prevented and treated. It is characterized by persistent airflow limitation. Airflow restriction develops progressively, with an increase in the chronic inflammatory response of the airways and lungs to harmful particles or gases. Acute exacerbations and comorbidities affect the severity of the patient's overall disease.

Rehabilitation epidemiology of chronic obstructive pulmonary disease

This patient has a large number of patients, a high mortality rate, and a heavy socio-economic burden, which has become an important public health issue affecting human health. COPD currently ranks 4th in the global cause of death, and according to World Bank / WHO estimates, COPD will rank 5th in the world's economic burden of disease by 2020. An epidemiological survey in China shows that the prevalence of COPD in people over 40 years of age is 8.2%, and the prevalence is very high.

Causes of chronic obstructive pulmonary disease rehabilitation

Individual factor

Certain genetic factors can increase the risk of COPD. A known genetic factor is alpha 1 -antitrypsin deficiency. Severe 1-antitrypsin deficiency is associated with emphysema formation in nonsmokers. Emphysema caused by 1-antitrypsin deficiency in China has not been formally reported so far. Bronchial asthma and airway hyperresponsiveness are risk factors for COPD. Airway hyperresponsiveness may be related to certain genetic and environmental factors of the body.

envirnmental factor

1. Smoking.

2. Occupational dust and chemicals.

3 Air pollution.

4 infection.

5. Socioeconomic status.

Clinical manifestations of chronic obstructive pulmonary disease rehabilitation

(1) Chronic cough: usually the first symptom. The cough was intermittent at the beginning, heavier in the morning, and later in the morning or evening or throughout the day, but the cough at night was not significant. Few cases have cough without sputum. In some cases, although there is obvious airflow limitation but no cough symptoms.

(2) Sputum: A small amount of mucus sputum is usually coughed after coughing, and some patients are more in the early morning; when the infection is combined, the amount of sputum increases and purulent sputum is often present.

(3) Shortness of breath or dyspnea: It is a hallmark of COPD and the main cause of anxiety in patients. It only appears during labor early and then gradually increases, so that shortness of breath is felt during daily activities and even at rest.

(4) Wheezing and chest tightness: not specific symptoms of COPD. Some patients, especially severe ones, have wheezing; tightness in the chest usually occurs after exertion, and is related to breathing difficulties and capacitive contractions such as intercostal muscles.

(5) Systemic symptoms: In the clinical course of the disease, especially in heavier patients, systemic symptoms may occur, such as weight loss, loss of appetite, peripheral muscle atrophy and dysfunction, mental depression and / or anxiety. Co-infection may be hemoptysis or hemoptysis.

Rehabilitation signs of chronic obstructive pulmonary disease

Early signs of COPD are not obvious. As the disease progresses, the following signs are often present:

(1) Inspection and palpation: abnormal thoracic morphology, including excessive expansion of the chest, increased anteroposterior diameter, widening of the inferior angle of the sternum below the xiphoid (upper abdomen angle), and swelling of the abdomen; Assisted breathing muscles participate in breathing exercises. In severe cases, contralateral chest and abdomen exercises can be seen. Leaning posture is often used when breathing is worse. Mucosa and skin cyanosis can occur in patients with hypoxemia. Edema of lower limbs and enlarged liver can be seen in patients with right heart failure.

(2) Percussion: Excessive inflation of the lungs reduces the heart dullness and lung and liver.

(3) Auscultation: Respiratory sounds of both lungs can be reduced, exhalation gas can be prolonged, dry rales can be heard during calm breathing, and wet rales can be heard at the bottom of the lungs or other lung fields; ^[1]

Laboratory tests and other monitoring indicators for chronic obstructive pulmonary disease rehabilitation

1. Pulmonary function test: Pulmonary function test is an objective indicator for judging airflow limitation, and its repeatability is good, which is of great significance for the diagnosis, severity evaluation, disease progression, prognosis and treatment response of COPD.

2. Chest X-ray examination: X-ray examination is of great significance in determining pulmonary complications and distinguishing it from other diseases (such as pulmonary interstitial fibrosis, tuberculosis, etc.).

3 Chest CT examination: CT examination is generally not used as a routine examination, but CT examination is useful in differential diagnosis.

4 Blood gas examination: Patients with COPD who have respiratory failure or right heart failure should have a blood gas examination when FEV1 <40% of the expected value.

5. Other laboratory examinations: PaO2 <55 mmHg, hemoglobin and red blood cells can increase, hematocrit> 55% can be diagnosed as erythrocytosis. A large number of neutrophils can be seen in sputum smears during concurrent infection. Various pathogens can be detected in sputum culture. The common ones are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Klebsiella pneumoniae, etc. ^[2]

Rehabilitation severity scale of chronic obstructive pulmonary disease

The severity of COPD needs to be determined based on the patient's symptoms, pulmonary dysfunction, and the presence of comorbidities (respiratory failure, heart failure). The decline in FEV1, which reflects the degree of airflow limitation, has important reference significance. There are 4 levels of COPD according to the severity of lung function:
Grade I (mild COPD): It is characterized by mild airflow limitation (FEVl / FVC <70% but FEVl80% of the expected value), usually with or without cough and sputum. At this time, the patient may not realize that his lung function is abnormal.
Grade (moderate COPD): It is characterized by further deterioration of airflow limitation (50% FEV1 <80% of the predicted value), symptoms progress and shortness of breath, and shortness of breath is more pronounced after exercise. At this time, patients often go to the hospital due to dyspnea or worsening of the disease.
Grade III (severe COPD): It is characterized by further deterioration of airflow limitation (30% FEV1 <50% of the predicted value), shortness of breath exacerbated, and repeated acute exacerbations, affecting the quality of life of patients.
Grade (very severe COPD): severe airflow limitation (FEV1 <30% of the predicted value) or combined with chronic respiratory failure. The patient's quality of life is significantly reduced, and if acute exacerbation occurs, it may be life threatening.

Rehabilitation diagnosis of chronic obstructive pulmonary disease

1. Comprehensive collection of medical history for evaluation: When diagnosing COPD, the medical history should be comprehensively collected, including symptoms, previous history and systematic review, and history of exposure.

2. Diagnosis: The diagnosis of COPD should be based on comprehensive analysis of clinical manifestations, history of exposure to risk factors, signs, and laboratory tests. Consider the main symptoms of COPD as chronic cough, sputum and / or dyspnea, and a history of exposure to risk factors; the presence of incompletely reversible airflow limitation is a necessary condition for the diagnosis of COPD. Pulmonary function is the gold standard for the diagnosis of COPD. FEV1 / FVC <70% after bronchodilator use can be identified as incomplete reversible airflow limitation. COPD may be with or without clinical symptoms in the early stages of mild airflow restriction. A chest X-ray can help determine the extent of lung over-inflation and distinguish it from other lung diseases.

Stages of rehabilitation for chronic obstructive pulmonary disease

The course of COPD can be divided into acute exacerbations and stable periods. The acute exacerbation period of COPD refers to patients who continue to deteriorate beyond their daily condition and need to change the routine medication of basic COPD. The stable period refers to patients with stable or mild symptoms such as cough, expectoration, and shortness of breath.

Rehabilitation of chronic obstructive pulmonary disease

The role and indications of pulmonary rehabilitation in chronic obstructive pulmonary disease

Pulmonary rehabilitation is a multidisciplinary exercise and education program for COPD patients and their families (or caregivers). Although respiratory rehabilitation does not significantly improve the lung function of patients, multiple studies have shown that pulmonary rehabilitation can not only relieve the symptoms of dyspnea in patients with COPD, improve patients' endurance of exercise and health-related quality of life (HRQL), reduce the rate of acute exacerbations and length of hospital stay, but also It can improve the psychological barrier and social adaptability of patients without psychological intervention, and has good social and economic benefits.

For a long time, pulmonary rehabilitation has traditionally been used as secondary care for patients with moderate to severe COPD. At present, pulmonary rehabilitation is not only suitable for patients with mild to severe COPD, but also for acute exacerbations and machinery after infection control. Ventilated COPD patients. Studies have found that patients with COPD of different severity of dyspnea can benefit from rehabilitation. Observations show that the recovery of COPD in the acute exacerbation period after infection control is conducive to the early discharge of patients.

The main content of pulmonary rehabilitation in chronic obstructive pulmonary disease rehabilitation

Exercise

Exercise is the core content of pulmonary rehabilitation. In the natural course of COPD, skeletal muscle depletion and dysfunction (SMD) and decreased cardiopulmonary function are the main reasons for the gradual decline of patients' mobility and exercise endurance, which seriously affects the HRQL of patients. Recent studies have shown that the decline in exercise capacity is more pronounced in patients with severe COPD than in the first second of forced breathing volume (FEV1). Exercise training can improve the aerobic and anaerobic metabolism of muscle cells, increase the capillary density of trained muscles, improve the ability of the cardiopulmonary system to coordinate work, and significantly increase the maximum oxygen uptake (VO2m ax) of COPD patients, thereby improving breathing difficulties and increasing Exercise endurance and HRQL.

Exercise method

Pulmonary rehabilitation can be divided into 3 types according to the exercise site. (1) Lower limb muscle exercise: It is the main component of exercise training, including walking, running, stair climbing, plate exercise, power cycling, etc .; (2) Upper limb muscle training: It helps to strengthen the strength and endurance of auxiliary respiratory muscles, in recent years In the past, it has gradually gained attention, including upper limb power meter method, weight lifting, ball throwing, etc .; (3) Whole body exercise: housework such as planting flowers, sweeping the floor, etc., various traditional physical exercises, swimming and rehabilitation exercises, etc. Nourishing exercises, Taijiquan, and Taiji sword are peculiar sports methods in China. They can not only adjust the patient's breathing ratio, but also relieve tension and anxiety. They are also effective methods of whole-body exercise. But the lack of quantification standards for exercise intensity and effects is poorly comparable. In addition, according to the subjective effort of the patient, it can be divided into active and passive movements. For patients with respiratory failure, simple handshake and moving toes are also active rehabilitation activities. Although there is no obvious movement, they can exercise related neuromuscular functions. Passive exercise methods include massage, massage, acupuncture, and neuromuscular electrical stimulation. Neuromuscular electrical stimulation is characterized by low-voltage stimulation of peripheral muscle contraction to exercise related muscle functions. It has been used in patients with acute exacerbation or chronic bedridden after infection control. We found that for COPD in the acute exacerbation period after infection control, early encouragement of active movements such as handshake, upper and lower extremities, and passive activities such as massage, massage, acupuncture, and neuromuscular electrical stimulation are beneficial to patients' early recovery.

Exercise training time

The effect of lung rehabilitation is directly proportional to the duration of exercise training. Therefore, long-term exercise rehabilitation training is recommended for patients with COPD. However, there are different opinions on how long exercise training should take effect. Some scholars have suggested that pulmonary rehabilitation should be performed 3-5 times a week for at least 2-3 months. There are also opinions that patients with mild to moderate COPD can benefit from short-term pulmonary rehabilitation, but patients with severe COPD need at least 6 months of pulmonary rehabilitation to receive the same effect. In order to improve HRQL and exercise tolerance, most patients with COPD need to undergo pulmonary rehabilitation for at least 8 weeks, and 3 times a week for 1 h. Therefore, COPD patients should take exercise rehabilitation as a part of their lives, actively participate in household chores such as planting flowers and sweeping the ground, or actively carry out various sports.

Exercise intensity

Exercise intensity is an important factor affecting the rehabilitation effect of exercise, and there is a positive dose-response relationship between the two. Although low-intensity (less than 30% of the maximum amount of exercise) or high-intensity (more than 60% of the maximum amount of exercise) training can increase the patient's exercise endurance, the oxidase in the training muscles increases after high-intensity exercise, and the exercise capacity is significantly improved. Physiological responses (such as blood lactate concentration, maximum oxygen consumption, etc.) have also improved significantly, so they benefit more. But high-intensity exercise is not suitable for patients with severe illness and poor compliance. Therefore, in principle, exercise intensity should follow the principle of individualization. For patients with more severe severity, exercise intensity should be gradually increased.

At present, the cardiopulmonary exercise test is a standard method for quantifying and evaluating exercise intensity, including power cycling and treadmill exercise tests, of which power cycling is more commonly used. Symptom-limited maximal exercise test can be used to obtain the patient's maximum exercise volume, maximum oxygen uptake and maximum heart rate. 50% -80% of the maximum exercise or maximum oxygen uptake is often taken as the lower limb exercise intensity, high-intensity exercise refers to greater than 60% of the maximum exercise or maximum oxygen uptake. However, the cardiopulmonary exercise test requires certain equipment conditions, which limits its application in home and community rehabilitation exercises. The target heart rate (THR) and dyspnea are relatively easy to obtain and can be used as a quantitative index of exercise intensity in most patients with COPD.

Respiratory muscle training

COPD has a systemic inflammatory response.Inflammatory factors can cause weight loss and skeletal muscle atrophy. Malnutrition causes various types of muscle fiber atrophy and changes in their composition.At the same time, COPD's over-inflated lung can cause abnormalities in the thoracic and diaphragm muscles. Factors can cause inspiratory muscle dysfunction. Although inspiratory muscle training cannot significantly improve the 6-minute walking distance of patients, it can increase the inspiratory muscle strength and endurance, reduce subjective and labor dyspnea, and improve health-related quality of life. The American College of Thoracic, Cardiovascular and Pulmonary Rehabilitation (ACCP / AACVPR) also recommends that respiratory muscle training be added to the lung rehabilitation program. At present, respiratory muscle training methods mainly include controlled deep and slow breathing exercises, lip-belly breathing exercises, resistance breathing exercises, and breathing gymnastics. Respiratory muscle rehabilitation exercises are simple, non-invasive, painless, low-cost, and easily accepted by patients. They can be widely carried out in families and communities. However, the choice and treatment of reasonable breathing exercises for patients with different levels of COPD need to be further explored.

Effective cough and expectoration methods

COPD patients have a history of chronic bronchitis for many years. The symptoms of cough and sputum are obvious every winter and spring, and they exacerbate acutely and even inflammation of the lungs. Failure to cough and expel sputum in a timely and effective manner can lead to aggravation of the condition, persistent inflammation of the lungs, and even concurrent respiratory failure. Therefore, patients should be encouraged to perform effective cough and sputum. The specific method is: sit as straight as possible, after inhaling deeply, press the abdomen with both hands, lean the body slightly forward, continuously cough, contract the abdominal muscles when coughing, and forcefully expel the sputum deep in the lungs. Clinically, cough training is usually used in combination with position changes, chest taps and aerosol inhalation to keep the airway clean and unobstructed.

Nutrition therapy

Due to the high metabolic state of COPD in the resting state, and insufficient long-term nutritional intake and incomplete absorption of nutrients, COPD patients often suffer from malnutrition to varying degrees. Long-term malnutrition can cause skeletal and respiratory muscle dysfunction in patients with COPD. The inspiratory muscle strength of malnourished patients is 30% lower than normal nutrition. After improving nutritional status of malnourished patients, the inspiratory muscle function can be partially restored, breathing Difficulties can be partially improved. Malnutrition also increases the chance of infection in patients with COPD and is one of the determinants of patient health and disease prognosis. Therefore, it is important to provide patients with reasonable nutritional support. For the diet of COPD patients, you can eat less often, eat enough energy, and increase the amount of fish, protein and fruits.

Method for improving chronic pulmonary obstructive pulmonary disease rehabilitation effect

Increase the amount of exercise

At present, the methods for increasing the amount of exercise and improving the effects of exercise include oxygen inhalation, non-invasive positive pressure assisted ventilation, inhalation of bronchodilators and interval training.

Oxygen

Inhaling oxygen during COPD exercise can effectively correct exercise-induced hypoxemia, reduce hypoxic breathing work, enable COPD patients to achieve higher training intensity, and significantly increase exercise endurance. For COPD patients, a slight increase in inhaled oxygen concentration can improve exercise tolerance. This effect is more pronounced when the inhaled oxygen concentration reaches 50% and above, and it is also effective for patients with non-hypoxemia. The latest research found that inhaling a high helium-oxygen mixture can also reduce breathing difficulties in COPD patients, increase the intensity and duration of exercise, and thereby improve the effect of lung rehabilitation.

Noninvasive positive pressure ventilation

COPD patients have varying degrees of airflow limitation, which is related to lung hyperinflation. Under exercise conditions, patients with COPD need a greater tidal volume to meet the ventilation needs during exercise, so breathing work increases, and respiratory muscles are prone to fatigue. Non-invasive positive pressure assisted ventilation during exercise can reduce the patient's breathing work, increase minute ventilation, effectively relieve respiratory muscle fatigue, thereby reducing the symptoms of shortness of breath during exercise, prolonging exercise time, and increasing exercise tolerance. Some studies have found that short-term non-invasive positive pressure assisted ventilation in patients with severe COPD in the stable phase can improve the exercise intensity of patients. Non-invasive positive pressure ventilation mode can choose pressure support ventilation (PSV) and proportional assist ventilation (PAV), and combined with positive end expiratory pressure (PEEP), inspiratory pressure support can improve ventilation, expiratory pressure support is beneficial Improve ventilation function, increase blood oxygen partial pressure. A prospective controlled study of pulmonary rehabilitation with non-invasive positive pressure ventilation for 29 days showed that patients' FEV1, blood gas, and health-related quality of life were significantly improved.

Inhaled bronchodilator

Bronchodilators can improve airflow obstruction in patients with COPD, and meet the increased ventilation needs during exercise. However, because COPD patients often have muscle fatigue in the lower limbs, which affects the intensity and time of exercise, patients cannot fully benefit from bronchodilators, but muscle fatigue can be improved through exercise. Therefore, the use of bronchodilators and exercise have a synergistic effect. Evidence has shown that even in patients with severe COPD, pulmonary rehabilitation is more effective with bronchodilators. In addition, the use of bronchodilators before exercise rehabilitation is helpful for enhancing patient confidence and helping to achieve a predetermined amount of exercise.

Education and management

Pulmonary rehabilitation in patients with COPD is a long-term job, and it is important to provide patients with reasonable and effective educational guidance and management. Through education and management, patients and related personnel can improve their understanding of COPD and their ability to deal with diseases, improve patients' compliance with pulmonary rehabilitation and other treatments, reduce repeated aggravation, and improve quality of life. The content of education mainly includes the pathophysiology and clinical basics of COPD, smoking cessation, the importance of lung rehabilitation, prevention, early recognition and treatment of acute exacerbations.

Psychological intervention

The long-term recurrence of COPD symptoms obviously aggravates the psychological burden of patients, causing great psychological harm to patients. Most patients do not cooperate with pulmonary rehabilitation and other related treatments due to anxiety, depression and other disorders. In clinical work, we should routinely evaluate the psychological disorders of patients. For mild patients, we can help patients build confidence and change from passive to active through psychological support such as communication, induction, inspiration, and motivation. For patients with severe psychological disorders, professional psychological treatment should be performed. The collective rehabilitation exercise for inpatients is helpful for patients to overcome their psychological barriers and actively cooperate with rehabilitation treatment.

COPD Rehabilitation of chronic obstructive pulmonary disease

Acute exacerbation is an important cause of decreased lung function and quality of life and even death in patients with COPD. In the absence of pulmonary rehabilitation, despite the best medical treatment, lung function and quality of life in patients with acute exacerbation of COPD (AECOPD) can still worsen during hospitalization, and it takes considerable time to recover or incomplete recovery To basic level. Some studies have studied the feasibility and effect of early lung rehabilitation exercise in 1826 AECOPD patients (within 10 days after remission) through a retrospective cohort, and found that regardless of the severity of breathing difficulties, lower intensity early pulmonary rehabilitation in AECOPD patients Both are feasible and significantly improve the patient's exercise endurance. In a prospective controlled study, Murphy et al. Studied the effect of early pulmonary rehabilitation (on the day of discharge, 6 weeks) on 31 patients with AECOPD, and found that patients with AECOPD who had undergone early pulmonary rehabilitation had significantly improved symptoms of exercise tolerance, quality of life, and dyspnea. . Therefore, in order to allow more patients with COPD to benefit more from pulmonary rehabilitation, early rehabilitation exercises should be performed for patients with AECOPD.

Timing

Although the feasibility and effect of early pulmonary rehabilitation in patients with AECOPD have been recognized, it has not been demonstrated when early pulmonary rehabilitation will be performed during the acute exacerbation period to benefit patients from pulmonary rehabilitation to the greatest extent. After the control of the acutely exacerbated infection, exercise rehabilitation can be started, which is conducive to shortening the length of hospitalization. For patients with tracheal intubation and mechanical ventilation, lung rehabilitation is performed after infection control, which is conducive to offline and offline cough and sputum ^{[ 3]} .

Exercise volume and exercise method

The amount of exercise should start from a small intensity, gradually and gradually, until it is maximized. For those who are unable to complete the scheduled training program due to difficulty breathing, intermittent exercise is feasible. The so-called intermittent exercise, which alternates exercise with rest, can reduce dyspnea and lactic acid accumulation in muscles during exercise, thereby increasing exercise volume and increasing exercise intensity. The initial exercise methods mainly include passive movements such as massage, massage, myoelectric stimulation, and shaking hands, turning over, changing the sitting position, standing on a bed, walking, non-invasive ventilation and / or active activities under oxygen.

In short, comprehensive pulmonary rehabilitation can improve the symptoms of dyspnea, improve exercise tolerance and HRQL in patients with COPD. In the pulmonary rehabilitation of COPD patients, early, combined with different methods and individualized principles should be followed, and a planned and feasible rehabilitation program should be established for each individual. For a long time, due to the relatively lagging concept of treatment of many patients with COPD, strong dependence on drug therapy, neglect or unable to understand the importance of active pulmonary rehabilitation, COPD patients have not undergone low-cost, high-efficiency pulmonary rehabilitation. Therefore, respiratory medical staff should actively encourage patients with COPD to perform comprehensive pulmonary rehabilitation.