PR 1.0 PULMONARY REHABILITATION: Pulmonary rehabilitation is a restorative and pre-ventive process for patients with chronic respirato-ry dia.
PR 2.0 DESCRIPTION/DEFINITION: Pulmonary rehabilitation (PR) has been defined as a “multi-disciplinary program of care for patients with chronic respiratory impairment that is individ-ually tailored and designed to optimize physical and social performance and autonomy.”1
As lung rerve declines, dyspnea worns and in-dependent daily activity performance erodes. PR provides multidisciplinary training to improve the patient’s ability to manage and cope with progres-sive dyspnea.2
Although PR efforts are often focud on patients with chronic obstructive pulmonary dia (chron-ic bronchitis and/or emphyma),3-6other condi-tions appropriate for this process include, but are not limited to, patients with asthma,7interstitial dis-ea,8bronchiectasis,8cystic fibrosis,9-11chest wall dias,8neuromuscular disorders,12,13ventilator dependency,14,15and before and after lung surgery for transplantation,16volume reduction,17,18or can-cer.19,20
PR rvices include critical components of asss-ment, physical reconditioning, skills training, and psychological support.2,21Additional PR rvices may include vocational evaluation and counl-ing.2
2The PR program must be tailored to meet the needs of the individual patient, addressing age-spe-cific and cultural variables, and should contain pa-tient-determined goals, as well as goals established by the individual team discipline.20,23Both patients and families participate in this training adminis-tered by health care professionals. The pul-monary rehabilitation rvices are overen by a medical director to assure appropriate performance by the program staff and to assure proper rvice delivery.2
This guideline is appropriate for pediatric, adult, and geriatric patients in whom clear indications for rehabilitation are prent and who posss the nec-essary cognitive and physical capabilities.
Bad on the individualized asssment the follow-ing areas of education and training should be con-sidered:2
2.1pulmonary anatomy and physiology includ-
ing the pathophysiology of lung dia24-26
2.2description and interpretation of medical
tests27-33
2.3bronchial hygiene techniques34,35
2.4exerci conditioning and techniques that
include:36
2.4.1breathing retraining37
2.4.2 endurance, strength, and flexibility
training
2.4.2.1upper extremity37-42
2.4.2.2lower extremity37,41
2.4.3 ventilatory muscle training (its role
is still undetermined, since no evidence
exists that it contributes to functional im-
provement when added to a traditional
upper and lower extremity exerci train-
抖音语录ing program).1,36
2.4.4 energy conrvation as it applies to
activities of daily living43,44
2.5indications, actions, and side-effects of
medications including non-prescription prod-ucts, such as vitamins, over-the-counter medi-cations, and herbal remedies6
2.6 functional lf-management
2.6.1 lf asssment and symptom man-
agement45
2.6.2 infection control with emphasis on
avoidance, early intervention, and immu-
AARC Clinical Practice Guideline Pulmonary Rehabilitation
nization46-48
2.6.3environment control
2.6.4 indications for eking additional
medical resources
2.7sleep disturbances, eg, insomnia and sleep
apnea as they relate to chronic lung dia
2.8xuality and intimacy49,50
2.9nutrition51-54
2.10smoking cessation55-57
2.11psychosocial intervention and support21,58
2.12available community rvices, including
patient/family support groups59
2.13advance care planning60,61
2.14travel issues62
2.15recreation/leisure activities63
2.16stress management
2.17indications for oxygen, and methods of de-
livery64
PR 3.0 SETTINGS:
PR may take place in, but is not limited to:
3.1 the inpatient tting, including medical cen-
ter, skilled nursing facility, or rehabilitation hospital2
3.2the outpatient tting2,65
3.2.1 outpatient hospital-bad clinic
3.2.2 comprehensive outpatient rehabili-
tation facility (CORF)
3.2.3 physician’s office
3.2.4 alternate or extended care facility
3.2.5 patient’s home65
PR 4.0 INDICATIONS:
The indications for PR include the prence of res-piratory impairment potentially responsive to the techniques available.1,2,36Such impairment may be manifested as:
4.1dyspnea experienced during rest or exertion
4.2hypoxemia, hypercapnia
4.3reduced exerci tolerance or a decline in
the patient’s ability to perform activities of daily living
4.4an unexpected deterioration or worning
symptoms against a background of long-stand-ing dyspnea and a reduced but stable exerci tolerance level
4.5the need for surgical intervention (pre- and
postoperative lung rection, transplantation, or volume reduction)
金字塔模式4.6chronic respiratory failure and the need to
initiate mechanical ventilation
4.7ventilator dependence
4.8increasing need for acute care intervention,
including emergency room visits, hospitaliza-tions, and unscheduled physician office visits PR 5.0 CONTRAINDICATIONS:
The initial asssment of the patient should estab-lish his or her willingness to participate in the reha-bilitation process. The prence of certain condi-tions would make successful completion of the re-habilitation process unlikely.2
5.1 Potential contraindications to PR include is-
chemic cardiac dia, acute cor pulmonale, vere pulmonary hypertension, significant hepatic dysfunction, metastatic cancer, renal failure, vere cognitive deficit, and psychiatric dia that interferes with memory and com-pliance. The decision to provide or withhold PR should be bad on a thorough, individual-ized asssment.
5.2Substance abu without the desire to cea
u would riously interfere with successful PR.
5.3Physical limitations such as poor eyesight,
impaired hearing, a speech impediment, or or-thopedic impairment may require modification of the PR tting but should not interfere with participation in a PR program.
PR 6.0 HAZARDS/COMPLICATIONS: Hazards/complications associated with PR are pri-marily related to the exerci program. During ex-erci the cardiovascular and ventilatory systems must be able to respond to incread demands. Ex-erci can lead to muscle or ligament injuries.
PR 7.0 LIMITATIONS OF METHOD:
7.1Patient related
7.1.1 The patient may have a dia pro-
cess that has progresd to the stage
where rehabilitation is not possible.
7.1.2The patient may not adhere to or
complete the program becau it appears
to be complicated or becau of a n of
hopelessness, depression, or a lack of mo-
tivation.
7.1.3The patient/patient family may be
reluctant to make changes in their usual
program, medications, start new therapy,
高校助学贷款quit smoking, u supplemental oxygen,
or exerci.23
7.1.4There might be concerns or limita-
tions in transportation.
7.1.5Financial resources might not be
available.
7.1.6The patient may have to stop the pro-
gram becau of an acute exacerbation, or
worning of another medical condition.
7.2Related to the health care system
7.2.1Reimburment by intermediaries or
third-party payers is not standardized. PR 8.0 ASSESSMENT OF NEED:
8.1The patient must be under the care of a
physician for the pulmonary condition for which he or she needs rehabilitation. Appropri-ate members of the PR team participate in the patient’s asssment. The initial evaluation should include the medical history, diagnostic tests, current symptoms, physical asssment, psychological, social, or vocational needs, nu-tritional status, exerci tolerance, determina-tion of educational needs, and the patient’s abil-ity to carry out activities of daily living.2
8.2Areas to be evaluated and reviewed in-
clude:2
8.2.1effect on quality of life
8.2.2pulmonary function asssment, in-
cluding arterial blood gas analysis
8.2.3u of medical resources such as
hospitalizations, urgent care/emergency
room visits, or physician visits
8.2.4exerci ability
8.2.5dependence vs independence in ac-
tivities of daily living
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8.2.6 impairment in occupational perfor-
mance
8.2.7psychosocial problems such as anxi-
ety or depression
8.2.8oxygen saturation at rest, with activ-
ity, and possibly during sleep
8.2.9co-morbidity
8.2.10smoking history
8.2.11motivation for rehabilitation, in-
cluding commitment to spending the time
necessary for active program participation
8.2.12current medications
8.2.13appropriate blood tests
8.2.14electrocardiogram
8.2.15chest radiograph
8.2.16 social support
8.2.17potential need for assistive devices,
eg, walker, wheel chair
8.2.18adherence to recommended treat-
ment modalities
8.2.19physician support available to patient
8.2.20availability of transportation and
patient/family desire to u what may be
available
8.2.21financial resources
PR 9.0 ASSESSMENT OF OUTCOME:
9.1Evidence exists for the effectiveness of PR
with respect to exerci tolerance, utilization of health care resources, and quality of life.1,36,66-69 There is some evidence that PR may improve survival in patients with COPD.36,70-73The ef-fectiveness of PR can best be established by comparing the baline condition of the patient to his or her condition as a conquence of par-ticipation in the PR program and should in-volve both qualitative and quantitative mea-sures. Such measurements should include:
9.1.1 indicators of health related quality
of life67,74-81including a reduction in dysp-
nea5,65,67,77,82,83
9.1.2 enhanced ability to perform activi-
ties of daily living including energy con-
地暖清洗机rvation4,84
9.1.3incread exerci tolerance and
performance37,41,67,76,77,79,84-88
9.1.4 decread respiratory symptoms, eg,
frequency of cough, sputum production,
wheezing
9.1.5 incread knowledge about pul-
monary dia and its management89-91
9.1.6 reduced need for medical rvices
including outpatient treatment and hospi-
tal admission70,87,92,93
9.1.7 incread ventilator-free time in the
ventilator-dependent patient
9.1.8 return to productive employment
9.2Documentation and data collection can de-
velop information regarding the cost-effective-ness of PR.70,87,92,93
9.3The benefit of long-term follow-up, includ-
ing maintenance programs, should be evaluated.
9.3.1educational/recreational support
group
9.3.2independent maintenance exerci
9.3.3scheduled, individualized, on-going
exerci/educational input from PR team 10.0 RESOURCES:
10.1Personnel
The number of disciplines contributing to a PR program varies with the size and scope of the PR program and the availability of tho disciplines within the tting. Members might include a res-piratory care practitioner, registered or licend nur, physical therapist, pharmacist, occupa-tional therapist, dietitian, social worker, exerci physiologist, chaplain, speech therapist, and mental health professional.2All personnel should be trained in basic life support techniques and, if possible, advanced cardiac life support.
10.1.1 Medical director: should be a li-
cend physician with an interest in and
knowledge of PR, pulmonary function,
and exerci evaluation.
10.1.2Program director/coordinator:
should be trained in health-related profes-
sion and have clinical experience and ex-
perti in the care of patients with chronic
lung dia. She or he should understand
the philosophy and goals of PR and be
knowledgeable in administration, market-
ing, education, patient training, and ob-
taining reimburment.
10.1.3 Team members: each member
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should be well-trained in his or her spe-
cialty, demonstrate the ability to establish
rapport with and convey the necessary
knowledge and skills to patients, and have
水芙蓉
a good working knowledge of the skills of
fellow team members. Each team member
should be qualified in their area of exper-
ti to access the patient’s needs, provide
appropriate intervention, and monitor pa-
tient outcomes.94The posssion of cre-
dentials appropriate to each specialty is
recommended, as well as appropriate li-
censing for each state. Persons responsi-
ble for pulmonary function testing, blood
民族园gas analysis, exerci testing, and tho
engaged in any patient educational train-
ing concerning needed therapy should
demonstrate the knowledge and skills
specified in the relevant AARC Clinical
Practice Guidelines.33-35,64,95-99The infor-
mation and recommendations provided to
patients should be evidence-bad and
consistent across the program. Each team
member must be aware of the content of
each discipline’s educational content.
10.2Physical facilities
The physical area for PR can vary greatly de-pending upon program structure, patient popu-lation, needs, and resources. The site should provide an appropriate environment with ade-quate space, few interruptions or other distrac-tions, sufficient lighting and temperature con-trol, and comfortable ating. It is esntial to have adequate parking and handicap access.
10.3Patient education materials97
10.3.1workbooks and videotapes90
10.3.2lung and skeletal models
10.3.3anatomical posters
10.4Equipment
10.4.1stethoscope
10.4.2manual sphygmomanometer
10.4.3pul oximeter33
10.4.4supplemental oxygen source
10.4.5access to laboratory for arterial
blood gas analysis95
10.4.6stopwatch
10.4.7calibrated cycle ergometer or mo-
torized treadmill (Measured walking dis-
tance may be ud if an ergometer or
treadmill is not available.)98
10.4.8 free-weights or elastic bands
10.4.9patient’s own equipment, eg, me-
tered-do inhaler and spacer, compressor
nebulizer for home u99
10.4.10emergency plan and supplies95
10.4.11EKG monitoring during exerci,
if indicated, and defibrillation and crash
cart96
10.4.12spirometer
10.4.13peak flow meter
11.0 MONITORING:
11.1Patient: the following should be monitored
at baline and at appropriate intervals to assure validity of results and appropriateness of inter-vention:
11.1.1patient’s respon to progressive
and general reconditioning exercis in
conjunction with breathing techniques
11.1.2patient’s oxygen requirements at
rest and with exerci
11.1.3knowledge and skills acquisition:
demonstrations and questionnaires should
be ud to document evidence of change
11.1.4patient’s subjective comments
11.1.5progress in achieving goals estab-
lished at baline
11.2Patient clinical monitoring during sched-
uled, supervid ssion
11.2.1 patient appearance
11.2.2 vital signs
11.2.3cardiac telemetry, if needed
11.2.4 perceived exertion and dyspnea
(eg, u of Borg Scale)
11.2.5O2saturation via oximeter
11.3PR rvices: each program should estab-
lish clinical indicators that objectively measure the information and instruction provided to the patient and should document the outcomes.
Content, goal orientation, and applicability should be reviewed on a regular basis.
12.0 FREQUENCY:
Training and informational components of PR should be delivered in a systematic manner to as-sure that all patient care issues are addresd. There should be repetition sufficient to ensure retention of information and skills. Giving the patient too much information at one time may cau confusion. Easy-to-read patient education materials should be ud to complement and reinforce verbal instructions.97 Program schedules vary according to staff, facili-ties, resources, budget, and patient needs.100PR r-vices are commonly provided over a period of 12 hours per week for 6 or more weeks, governed by the patient’s individual needs.101Patients are en-couraged, when possible, to participate in an ongo-ing maintenance exerci program to sustain the training effect.
13.0 INFECTION CONTROL:
13.1The staff, supervisors, and physicians asso-
ciated with the PR program should be conver-sant with “Guideline for Isolation Precautions in Hospitals”102and develop and implement poli-cies and procedures for the program that comply with its recommendations for Standard Precau-tions and Transmission-Bad Precautions.
13.2The program manager and its medical di-
rector should maintain communication and co-operation with the mother institution’s infection control rvice and the personnel health rvice to help assure consistency and thoroughness in complying with the institution’s policies related to immunizations, post-exposure prophylaxis, and job- and community-related illness and exposures.103
13.3The importance of immunization for in-
fluenza48and pneumococcal pneumonia,47and avoidance of exposure during periods of high in-cidence of respiratory infections in the commu-nity should be stresd to patients. Staff mem-bers should receive the influenza vaccination.104
13.4Patients and staff members with signs and
symptoms of respiratory infection should avoid contact with patients.
13.5Adequate handwashing105and proper ven-
tilation with prescribed air exchanges should be assured.106
13.6 Equipment shared by patients much be
cleaned and maintained appropriately. Specific procedures are provided in the 2001 update of static lung volume measurement (Section 13.4-
13.7)107Proper cleaning methods for the pa-
tient’s personal therapeutic equipment should be regularly reinforced.59,97
14.0 AGE-SPECIFIC ISSUES:
Instructions should be provided and techniques de-scribed in a manner that take into consideration the learning ability and communications skills of the patient being rved.
14.1Infant and Neonatal: This Guideline does
not apply.
14.2Pediatric: This Guideline is appropriate
for children with indications who can be moti-vated and who can follow directions.
14.3Geriatric: This Guideline is appropriate
for members of the geriatric population with in-dications who are motivated and who can fol-low directions.
Pulmonary Rehabilitation Guideline Committee (The principal author is listed first):
John E Hodgkin MD F AARC, Co-Chair, Deer Park CA Lana Hilling CRT, Co-Chair, Concord CA
Phillip D Hoberty EdD RRT, Columbus OH Rebecca J Hoberty RRT, Hilliard OH
