Efficacy of aerobic physical retraining in a case of combined pulmonary fibrosis and emphysema syndrome: a case report.

INTRODUCTION: Combined pulmonary fibrosis and emphysema has recently been recognized as a syndrome but remains under-diagnosed. Neither clinical management nor therapeutic approaches have been clearly defined. Pulmonary rehabilitation has not been considered within the therapeutic options for combined pulmonary fibrosis and emphysema. In this case we explored the potential benefits of a specific aerobic physical retraining program in the management of combined pulmonary fibrosis and emphysema. CASE PRESENTATION: We describe the case of a 65-year-old Caucasian man with combined pulmonary fibrosis and emphysema and respiratory failure who was receiving long-term oxygen therapy. Our patient underwent physical retraining with moderate intensity aerobic and breathing exercises for four weeks. Clinical and motor tests, as well as questionnaires assessing quality of life and depression levels, were performed prior to and following the retraining. At the end of the retraining program a relevant reduction of long-term oxygen therapy requirement was registered; improvements in terms of physical performance, quality of life, and mood were observed in our patient but no change in respiratory parameters. CONCLUSIONS: A program of aerobic physical retraining appears to be beneficial to patients with combined pulmonary fibrosis and emphysema and may be considered as an additional therapeutic option.

Impact of pulmonary rehabilitation on quality of life and functional capacity in patients on waiting lists for lung transplantation.

OBJECTIVE: To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation. METHODS: Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures. RESULTS: Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46 ± 14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001). CONCLUSIONS: Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists.

Impact of pulmonary rehabilitation on quality of life and functional capacity in patients on waiting lists for lung transplantation / Impacto da reabilitacao pulmonar na qualidade de vida e na capacidade funcional de pacientes em lista de espera para transplante pulmonar

OBJECTIVE: To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation. METHODS: Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures. RESULTS: Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46 ± 14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001). CONCLUSIONS: Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists. .

OBJETIVO: Avaliar o impacto de um programa de reabilitação pulmonar na capacidade funcional e na qualidade de vida de pacientes em lista de espera para transplante pulmonar. MÉTODOS: Pacientes em lista de espera para transplante pulmonar encaminhados a um programa de reabilitação pulmonar de 36 sessões. Os participantes foram avaliados no início e no final desse com o teste de caminhada de seis minutos (TC6) e com o questionário de qualidade de vida Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). O programa de reabilitação pulmonar foi composto por exercícios de fortalecimento muscular, treinamento aeróbico, acompanhamento clínico e psiquiátrico, acompanhamento nutricional, assistência social e palestras educacionais. RESULTADOS: Dos 112 pacientes encaminhados, 58 completaram o programa. A média de idade dos participantes foi de 46 ± 14 anos; sendo 52% do sexo feminino. Entre esses pacientes, 37 (47%) eram portadores de fibrose pulmonar, 13 (22%) tinham enfisema pulmonar, e 18 (31%), tinham outras doenças pulmonares em fase avançada. Houve uma melhora significativa na distância percorrida no TC6 ao final do programa (367 ± 136 m vs. 439 ± 114 m; p = 0,001), com um aumento médio de 72 m. Houve aumentos significativos nas pontuações dos seguintes domínios do SF-36: capacidade funcional, 22 pontos (p = 0,001); aspectos físicos, 10 (p = 0,045); vitalidade, 10 (p < 0,001); aspectos sociais, 15 (p = 0,001); e saúde mental, 8 (p = 0,001). CONCLUSÕES: O programa de reabilitação pulmonar teve um impacto positivo na capacidade de exercício e na qualidade de vida nos pacientes em lista de espera para transplante pulmonar. .

The nursing of a patient following lung volume reduction surgery.

Lung volume reduction surgery (LVRS) is an experimental surgical procedure that aims to alleviate the symptoms of breathlessness for patients with end-stage chronic emphysema. Emphysema (from the Greek for 'puff up') is a progressive chronic obstructive pulmonary disease (COPD) and risk factors include smoking and chronic infections. The disease causes the alveoli of the lung to over-expand and lose their elasticity (Schedel and Connolly, 1999). Advanced emphysema causes severe dyspnoea that significantly reduces the patient's quality of life.

Improving dyspnea management in three adults with chronic obstructive pulmonary disease.

This case report describes occupational therapy intervention for three adult outpatients with chronic obstructive pulmonary disease (COPD) at one large urban hospital. The occupational therapy intervention was based on the Management of Dyspnea Guidelines for Practice (Migliore, in press). The learning and practice of controlled breathing were promoted in the context of physical activity exertion in a domiciliary environment. In addition to promoting dyspnea management, the controlled-breathing strategies aimed to facilitate energy conservation and to increase perceived breathing control. Although no causality can be determined in a case study design, the patients' dyspnea with activity exertion decreased and their functional status and quality of life increased following goal-directed, individualized occupational therapy intervention combined with exercise training.

Impact of lung volume reduction surgery versus rehabilitation on quality of life.

This study aims at evaluating the effects of lung volume reduction versus respiratory rehabilitation on quality of life, assessed by three different questionnaires. Sixty emphysematous patients were randomised by computer to receive either surgery (n = 30) or rehabilitation (n = 30). Life quality was evaluated by the Nottingham Health Profile, the Short Form (SF)-36 item and the St George's questionnaires. As reported previously, dyspnoea index, forced expiratory volume in one second, residual volume, 6-min walk test and arterial oxygen tension improved after surgery more than after rehabilitation. Quality of life was significantly improved after surgery as follows Nottingham Health Profile physical mobility; SF-36 physical and social functioning, mental and general health, emotional role; St George's general, activity. At multivariate analysis 6- and 12-month changes after surgery of Short Form-36 physical functioning, general health, and St George's activity domains were significantly correlated with forced expiratory volume in one second, while Short Form-36 social functioning and Nottingham Health Profile isolation correlated with residual volume. Functional and especially symptomatic improvements persisted: dyspnoea index, residual volume, and Short Form-36 and St Georges's physical scores were still significant at 4 yrs. Surgery produces greater and longer effects than rehabilitation on quality of life by improving both physical and psychosocial domains. Symptomatic improvements persisted at 4 yrs.

Breathing out into water during subtotal immersion: a therapy for chronic pulmonary emphysema.

OBJECTIVE: To determine the importance of a breathing out into water exercise during subtotal immersion for emphysematous patients. DESIGN: Results of a respiratory function test and arterial blood gas analysis were examined to compare the programs of breathing exercise with and without the breathing out into water exercise. The breathing exercises in a pool filled with 38 degrees C water were performed 30 min/day, 5 days/wk, for 2 mo in 17 patients with stable chronic emphysema. Patients were randomly assigned to breathing exercise programs including subtotal water immersion with the nose and mouth either immersed (9 patients) or out of the water (8 patients) during exhalation. RESULTS: The ratio of %forced expired volume in 1 sec to forced vital capacity and %forced vital capacity at rest were significantly increased in the program with the breathing out into water exercise, but they did not change in the program without the breathing out into water exercise. A significant increase in peak flow was observed in the former program, although it did not change in the latter program. The maximal expiratory flow at 25% did not change in either program. Pao2 was significantly increased and Paco2 was significantly decreased in the former program, although a trend for a decrease in Paco2 was observed in the latter program. CONCLUSIONS: These results suggest that the breathing out into water exercise enhances the effects of a breathing exercise during immersion and is useful in rehabilitation for chronic pulmonary emphysema.

Clinical analysis of breathing exercise during immersion in 38 degrees C water for obstructive and constrictive pulmonary diseases.

Breathing exercises during immersion in 38 degrees C water were performed in 22 patients with bronchial asthma, pulmonary emphysema and constrictive pulmonary diseases. The patients entered a pool filled with 38 degrees C water to shoulder level. While standing, they breathed in deeply and breathed out slowly through the mouth into water while sinking the nose below the water level. This breathing method was repeated for 20 min. with a 5-min. rest out of water and this cycle was performed twice a day for two months. Respiratory function test and arterial blood gas analysis were examined before and after the two-month exercise program. FEV1.0% was significantly increased in patients with asthma and emphysema (p = 0.042 and 0.032, respectively) but did not change in patients with constrictive pulmonary diseases. %FVC, PF and Vmf25 did not change in any of the diseases. PaO2 was significantly increased in emphysematous patients (p = 0.0002) and PaCO2 was significantly decreased in asthmatic and emphysematous patients (p = 0.034 and 0.046, respectively). These results suggest that our breathing exercise by immersion is useful in patients with asthma and emphysema but is less effective in patients with constrictive pulmonary diseases.

[One year follow-up of pulmonary rehabilitation in patients with pulmonary emphysema--physiological outcome].

To evaluate the long-term effects of pulmonary rehabilitation on physiological outcome, 12 patients with pulmonary emphysema were enrolled in an inpatient pulmonary rehabilitation program for 6 weeks. After discharge from the hospital, they were followed up for 1 year. The pulmonary rehabilitation program consisted of breathing retraining, thoracic mobilization, exercise training, and patient education. Although the subjects did not participate in outpatient maintenance group sessions after their discharge, they continued breathing retraining and exercise training at home. Their vital capacity improved significantly, and was sustained over the course of the year; other pulmonary functions, however, did not change significantly. Maximum exercise load increased 31% after the rehabilitation program; although it was 18% higher than baseline at follow-up one year later, that was not a significant change. The follow-up data on exercise traming had generally deteriorated 1 year after the rehabilitation program. The change in maximum exercise load from baseline before and after the inpatient pulmonary rehabilitation program correlated closely with the change in maximum exercise load thereafter to follow-up one year later (R = 0.62). We conclude that it is pessible to estimate long-term change in exercise capacity on the basis of short-term changes achieved during inpatient pulmonary rehabilitation. It may be necessary to develop maintenance programs of some kind to help pulmonary emphysema patients retain the benefits of pulmonary rehabilitation over the longer term.

[Effects of a short-term pulmonary rehabilitation program on patients with chronic respiratory failure due to pulmonary emphysema].

To evaluate the effects of a short-term pulmonary rehabilitation program on dyspnea, exercise capacity, and lung function, 15 patients with chronic respiratory failure due to pulmonary emphysema were enrolled in such a program for 3 weeks as inpatients. The program consisted of pursed lip breathing, diaphragmatic breathing, respiratory muscle stretch gymnastics, and walking with synchronized breathing. Dyspnea as measured with a visual analogue scale at the end of a 6-minute walk before and after the program (49.7 +/- 4.0% to 24.2 +/- 3.8%) decreased significantly (p < 0.01). As a measure of functional exercise capacity, the 6-minute walking distance (226.9 +/- 32.4 m to 292.1 +/- 35.8 m) increased significantly (p < 0.01). As an indicator of maximal exercise capacity, endurance time on an incremental treadmill test did not improve. Spirometric data did not change during the study. Total lung capacity (TLC) (8.44 +/- 0.70 L to 7.58 +/- 0.74 L) and residual volume (RV) (5.13 +/- 0.53 L to 4.28 +/- 0.59 L) decreased significantly (p < 0.01). The findings suggest that this program relieves dyspnea, increases functional exercise capacity, and decreases TLC and RV on patients with chronic respiratory failure due to pulmonary emphysema.

Comparison of three protocols for breathing exercises during immersion in 38 degrees C water for chronic obstructive pulmonary disease.

Respiratory function test, arterial blood gas analysis, and ejection fraction were used to compare three protocols of breathing exercises during immersion in 38 degrees C water. Therapy was given for 2 mo to patients with stable chronic obstructive pulmonary disease. Protocol A consisted of a total exercise period of 20 min/wk (10 min/day, 2 days/wk) and was performed by 7 patients (5 cases of asthma and 2 cases of emphysema). Protocol B consisted of a total exercise period of 120 min/wk (20 min x 2 per day at 10:00 am and 3:00 pm, 3 days/wk) and was performed by 9 patients (6 asthmas and 3 emphysemas). Protocol C consisted of a total exercise period of 120 min/wk (20 min/day, 6 days/wk) and was performed by 8 patients (4 asthmas and 4 emphysemas). The ratio of forced expired volume in one second to forced vital capacity (FEV1.0%) was significantly increased in protocols B and C (P < 0.01). The ratio of forced vital capacity to the predicted normal value (%FVC) was not changed in any of the three protocols. A significant increase in peak flow was observed in protocols B and C (P < 0.05). The maximal expiratory flow at 25% (V25) was not changed in any of the three protocols. PaO2 was significantly increased and PacO2 was significantly decreased in protocol B (P < 0.01 and P < 0.05, respectively), whereas only PaCO2 was significantly decreased in protocol C (P < 0.05). Ejection fraction was increased in protocols B and C. These results suggest that exercise for a total period of 120 min/wk is preferable to that of 20 min/wk in COPD.

[Effects of pulmonary rehabilitation on vital capacity in patients with chronic pulmonary emphysema].

To evaluate the effects of pulmonary rehabilitation on pulmonary function, 15 patients with chronic pulmonary emphysema underwent pulmonary rehabilitation for six weeks as inpatients. Pulmonary rehabilitation consisted of relaxation techniques, breathing retraining, thoracic massage, physical exercise, and walking. In 8 of the 15 patients vital capacity increased by more than 200 ml (over 10%), and in 7 of the 15 patients the load of maximal exercise increased by more than 5 watts (over 10%). Increases in vital capacity were not associated with increases in maximal exercise load. The percent change in vital capacity associated with pulmonary rehabilitation correlated significantly with the percent change in tidal volume and the percent change in expiratory minute ventilation at the maximal load. The percent change in tidal volume at the maximal load correlated significantly with the percent change in maximum oxygen uptake. We attribute the increase in vital capacity to an improvement in thoracic cage movement. These findings suggest that pulmonary rehabilitation can increase vital capacity in some patients with chronic pulmonary emphysema, and that such an increase is not directly connected to increases in exercise capacity.

Effects of muscle relaxation therapy using specially designed plates in patients with pulmonary emphysema.

It has been suggested that respiratory muscle dysfunction plays a major role in the development of acute ventilatory failure in patients with chronic obstructive pulmonary disease (COPD). In this study, we devised a respiratory muscle relaxation maneuver using wedge-shaped wooden plates, with which pressure was exerted on the intercostal and accessory respiratory muscles by hand, or by tapping with a wooden hammer, for 15-20 minutes twice a day. The muscle relaxation maneuver was performed in 5 moderate to severe pulmonary emphysema patients for 4 weeks and in 7 emphysema patients for 6 weeks, and the effects on pulmonary function were examined. After the therapy, inspiratory capacity (IC) and vital capacity (VC) in both the 4 weeks-and 6 weeks-treated groups, and the forced expiratory volume in 1 second (FEV 1.0) in the 6 weeks-treated group were significantly increased, and CO2 retention had also improved. Daily peak expiratory flow (PEF) showed significant increases from 2 weeks after the initiation of the therapy. These results suggest that the respiratory muscle relaxation maneuver is effective for improving the pulmonary function of pulmonary emphysema patients.

[Pulmonary rehabilitation in pulmonary emphysema]. / Pulmonale Rehabilitation beim Lungenemphysem.

Respiratory rehabilitation in patients with pulmonary emphysema should be focussed first on the prevention and elimination of harmful inhalative factors, e.g. smoking habits and environmental or occupational pollution. In addition, distinct therapeutical procedures are mostly effective in preventing a progressive course of the disease and interrupting the vicious circle of dyspnea, physical inactivity and overall disability as well. In patients with advanced disease, mostly complicated by features of chronic respiratory insufficiency and cor pulmonale, long-term administration of oxygen often relieves symptoms, increases physical performance and may even reduce hospital admissions for a longer period. As a consequence, most patients with severe disability also suffer from severe psychological and social problems which should be considered more attentively within the concept of the overall rehabilitation program.

[Rehabilitation of respiration in outbreaks of bronchial superinfection]. / Rééducation de la respiration lors des poussées de surinfection bronchique.

The authors analized the effect of reeducation on patients with an exacerbated bronchial stasis and mucostasis. The group studied was composed of 103 patients suffering from chronic bronchitis, with or without pulmonary emphysema, bronchial asthma and bronchiectasis. Examination methods and breathing reeducation methods were briefly reported. Values measured before and after reeducation enabled by comparison the appreciation of this as an independent method. The rates of pulse (P less than 0.005), of breathing (P less than 0.001) and of systolic pressure (P less than 0.05) were influenced favourably by reeducation. The average quantity of sputum per day increased by 69% (P less than 0.001) specially in asthmatic patients, in itself an important improvement. After exercise there was a slight decrease of PaO2 and SaO2, but after 2 hours of rest, improved values for PaO2 (P less than 0.05), SaO2 (P less than 0.05) Raw (P less than 0.05) and SGaw (P less than 0.05) were noted. The transitory decrease was probably due to tired respiratory muscles and auxillary respiratory muscles. Breathing reeducation favourably affected the clinical conditions, the sputum production, mucostasis, blood-gases exchange, and decreased the airways obstruction. For a greater objectivity, different methodological approaches should also be considered.

Myofeedback: a new method of teaching breathing exercises in emphysematous patients.

The diaphragm of the emphysematous patient is low and limited in its excursions, producing an increased functional residual capacity and decreased pulmonary ventilation. This report describes our experiences with a new technique for 1) the training of abdominal-diaphragmatic (A-D) breathing and 2) the relaxation of accessory respiratory muscles in emphysematous patients. Abdominal muscle contraction during expiration has been shown to increase diaphragmatic excursions and, hence, pulmonary ventilation. Use of this technique has been limited, however, because of the difficulty in learning this breathing pattern. Through continuous audio and visual feedback of myoelectric potentials (myofeedback) from abdominal muscles, 12 patients learned A-D breathing. The lower rectus abdominis muscle was found to be the most suitable muscle for obtaining the myoelectric potentials. Similarly, by providing the patients with myofeedback from their accessory muscles, they decreased the use of these muscles, thus increasing their respiratory efficiency. With myofeedback, patients appear to learn new breathing patterns effectively and in fewer sessions than with conventional procedures.