1、稳定期稳定期COPD肺康复治疗肺康复治疗Pulmonary Rehab for the client with COPD in Stable Phase急性期急性期持续终身持续终身even during exacerbation,and ongoing综合管理综合管理within the concept of integrated care稳定期稳定期 COPD 肺康复治疗肺康复治疗Pulmonary Rehab for the client with COPD in Stable Phase可预防和可治疗的疾病可预防和可治疗的疾病preventable and treatable disea
2、se世界卫生组织将综合管理定义为世界卫生组织将综合管理定义为“这个概念将与诊断，治疗，管理，康复和健康促进相关的投入，交付，管理和组织服务整合在一起这个概念将与诊断，治疗，管理，康复和健康促进相关的投入，交付，管理和组织服务整合在一起”The World Health Organization defines integrated care as“a concept bringing together inputs,delivery,management and organization of services relatedto diagnosis,treatment,care,rehabi
3、litation and health promotion”跨学科的合作跨学科的合作，Interdisciplinary非多学科交叉，非多学科交叉，Not Multidisciplinary更显著的以患者为中心的方法更显著的以患者为中心的方法the most obvious being the patient-centredapproach将不同学科的方法整合成一个会诊会将不同学科的方法整合成一个会诊会integrate separate discipline approaches intoa single consultation2013 ATS&ERS：“Pulmonary rehabil
4、itation is a comprehensive intervention based on a thorough patientassessment followed by patient-tailored therapies that include,but are not limited to,exercise training,education,and behavior change,designed to improve the physical and psychological condition of people withchronic respiratory dise
5、ase and to promote the long-term adherence to health-enhancing behaviors”基于评估的，为患者量身定做的综合管理方案基于评估的，为患者量身定做的综合管理方案 不局限于运动，还包括教育，行为改变等不局限于运动，还包括教育，行为改变等 改善身体和心理，并促进长期的优化健康的行为改善身体和心理，并促进长期的优化健康的行为肺康复的介绍肺康复的介绍Introduction to Pulmonary Rehabilitation 肺康复是一项包括小组教育和运动治疗班的计划肺康复是一项包括小组教育和运动治疗班的计划 Pulmonary r
6、ehabilitation is a program of group education and exercise classes 肺康复计划包括患者评估，运动训练，教育，营养干预和心理支持肺康复计划包括患者评估，运动训练，教育，营养干预和心理支持 Pulmonary rehabilitation programs involve patient assessment,exercise training,education,nutritional intervention and psychosocial support 肺康复采取团队工作，需要参与者与医生，呼吸护士，物理治疗师和其他医疗团
7、队肺康复采取团队工作，需要参与者与医生，呼吸护士，物理治疗师和其他医疗团队的成员紧密合作的成员紧密合作 Pulmonary rehabilitation involves a team approach with the participants workingclosely with their doctors,respiratory nurses,physiotherapists and other allied healthteam members肺康复计划实施的流程肺康复计划实施的流程评估评估功能限制的原因功能限制的原因决定治疗计划决定治疗计划最佳治疗技术最佳治疗技术治疗疗效评估治疗疗
8、效评估适应证适应证禁忌证禁忌证注意事项注意事项调整和改良调整和改良呼吸困难呼吸困难&生活能力下降：恶性循环生活能力下降：恶性循环呼吸功能障碍呼吸功能障碍畏惧运动畏惧运动呼吸困难呼吸困难中度运动后中度运动后呼吸困难呼吸困难轻度运动后轻度运动后*=卧床静养卧床静养,恐惧抑郁恐惧抑郁,依赖氧疗依赖氧疗.更加畏惧更加畏惧呼吸困难呼吸困难日常生活中日常生活中去适应增加去适应增加*身体去适应身体去适应患者有意识和无意识的调整运动患者有意识和无意识的调整运动Pulmonary Rehabilitation for Management ofChronic Obstructive Pulmonary Dise
9、aseN Engl J Med 2009;360:1329-1335March 26,2009运动仍是运动仍是COPD患者肺康复的基石患者肺康复的基石肺康复运动治疗的一部分益处在于肺康复运动治疗的一部分益处在于 呼吸困难的中枢脱敏呼吸困难的中枢脱敏 减轻焦虑和抑郁减轻焦虑和抑郁 减轻动态过度通气减轻动态过度通气 改善骨骼肌肉功能改善骨骼肌肉功能上肢耐力训练：上肢耐力训练：UL Endurance Ex下肢耐力训练：下肢耐力训练：LL Endurance Ex上肢肌力训练：上肢肌力训练：UL Strength Ex运动训练的内容运动训练的内容 包括包括Exercise Trainning inc
10、ludes下肢肌力训练：下肢肌力训练：LL Strength Ex吸气肌肌力训练：吸气肌肌力训练：Inspir Muscle Ex柔韧性训练：柔韧性训练：Flexibility Ex北欧健步走北欧健步走Nordic Walking Exercise Program 现时，每日的步行已经被推荐为切实可行的可供替代的运动训现时，每日的步行已经被推荐为切实可行的可供替代的运动训练方案练方案 Recently,the number of steps per day has beensuggested as an alternative yet tangible target ofexercise tr
11、aining更多功能更多功能*更多趣味更多趣味*更多获益更多获益More Function*More Fun*More Found吸气驱动肌的压力驱动能力在吸气驱动肌的压力驱动能力在COPD患者中是降低的患者中是降低的The pressure-generating capacity of the inspiratory pump muscles is reduced in individuals with COPD1.肺过度通气的有害影响肺过度通气的有害影响deleterious effects of pulmonary hyperinflation2.运动不耐受和劳累性呼吸困难运动不耐受和劳
12、累性呼吸困难exercise intolerance and the perception of dyspnea吸气肌训练处方吸气肌训练处方Inspiratory Muscle Training Rx 阈值吸气肌训练器阈值吸气肌训练器threshold load IMT 超过超过30%的最大吸气压的最大吸气压exceeding 30%of an individuals maximal 30分钟分钟/天，天，5次次/周，周，4-12周周30min/d，5set/wks，4-12wks中国的技术：体外膈肌起搏中国的技术：体外膈肌起搏 将将2组小电极贴在双侧胸锁乳突肌外缘下组小电极贴在双侧胸锁乳突肌
13、外缘下1/3处，大电极贴在同组小电极对应的锁骨处，大电极贴在同组小电极对应的锁骨中线第二肋间的胸大肌皮肤表面中线第二肋间的胸大肌皮肤表面 每天每天1次，每次次，每次30分钟，分钟，16周周最大化运动效力的考虑最大化运动效力的考虑Maximizing the Effects of Exercise Training Considerations支气管扩张剂支气管扩张剂Bronchodilators合成激素代谢补充剂合成激素代谢补充剂Anabolic HormonalSupplementation氧气和氦氧混合气治疗氧气和氦氧混合气治疗Oxygen andHeliumhyperoxic Gas M
14、ixtures无创通气无创通气Noninvasive Ventilation呼吸策略呼吸策略Breathing Strategies助行器助行器Walking Aids(A)G ro u n d wal ki n g w i t h ro l l ator tro l l ey.(B)Latissi m u sd o rsi p u l l-d own m ac h i n e.(C)C h est b u tterflymach i n e a n d(D)Leg p ress mach i n e.循环训练计划循环训练计划Circuit TrainingA.平地步行：平地步行：Ground
15、 WalkingB.背阔肌下拉：背阔肌下拉：Latissimus DorsiPull-downC.胸部蝴蝶扩展：胸部蝴蝶扩展：Chest ButterflyD.下肢推压：下肢推压：Leg Press能改善能改善FEV 1，身体活动水平以及生活质量，身体活动水平以及生活质量Can improve in FEV 1(p=0.046),physical activity(p=0.007)and total SGRQ score(p=0.028)增加了血液中增加了血液中-endorphinincrease in beta-endorphin(p=0.012)Acu-TENS改善改善COPD患者的功能水
16、平，可能是因为患者的功能水平，可能是因为-endorphin诱导了支气管扩张的作用引起的诱导了支气管扩张的作用引起的 Acu-TENS improved the functional capacity of patients with COPD,probably due to thebronchodilation induced by beta-endorphin elevation1.are based on years of clinical experience and expert opinion,rather than evidence based2.is considered to
17、 be an interdisciplinary intervention rather than a multidisciplinary approach3.the 2006 definition emphasized the importance of stabilizing or reversing systemicmanifestations of the disease,without specific attention to behavior change跨学科的合作跨学科的合作 Interdisciplinary而非传统的多学科交叉而非传统的多学科交叉 Multidiscipl
18、inaryPulmonaryPulmonary rehabilitationrehabilitation Is an evidence based,multidisciplinary,andcomprehensive intervention for patients withchronic respiratory diseases who are symptomaticand often have decreased daily life activities.Integrated into the individualised treatment of thepatient pulmona
19、ry rehabilitation is designed toreduce symptoms,optimise functional status,increase participation,and reduce health carecosts through stabilising or reversing systemicmanifestations of the disease ATS/ERS statement on pulmonary rehabilitation (2006)American journal of respiratory and critical careme
20、dicine,173:1390-1413WHATWHAT ISIS PR?PR?A Multidisciplinary programme of care for patientswith chronic respiratory impairment that isindividually tailored and designed to optimisephysical and social performance and autonomy.BTS statement 2001NICENICE GUIDELINESGUIDELINES 20102010 Should be offered t
21、o all appropriate patients withCOPD including those who have had a recentadmission for an acute exacerbation.Should be offered to all patients consideringthemselves functionally disabled by COPD Should be available within a reasonable time ofreferral,held at times that suit patients inbuildings that
22、 are easy for patients to get to andhave good access for people with respiratorydisability.WhyWhy PulmonaryPulmonary RehabilitationRehabilitationMuscle weaknessFatigue,anxiety,isolationEvidenceEvidence forfor PRPREvidence (level la)Improvements in exercise tolerance Reduction in the sensation of dys
23、pnoea Improvement in health related quality of life(HRQoL).Evidence (level lb)Improvement in peripheral muscle strength andmass Reductions in number of days spent in hospital Evidence (level lla)or (level llb)Improvement in the ability to perform routineactivities of daily living Reductions in exace
24、rbations Reduction in anxiety and depression Improvements in exercise tolerance maintainedbetween 6 12 monthsAIMSAIMS Improve independence in daily functioning Improve knowledge of lung condition and promote self-management Increase muscle strength and endurance (peripheraland respiratory)Increase e
25、xercise tolerance and reduce dyspnoea Reduce length of hospital stay Improve health related quality of life Promote long term commitment to exercise.Garrod 2003 (Chartered society of Physiotherapy briefing)BENEFITSBENEFITS Reduction in number of days spent in hospital oneyear following pulmonary reh
26、abilitation (Griffiths2001)Reduction in the number of exacerbations inpatients who performed daily exercise when comparedto those who did not exercise (Guell 2000)Reduced exacerbations post pulmonary rehabilitation(Foglio 1999)These studies all demonstrate a decrease in lengthof stay in hospital for
27、 admissions post pulmonaryrehabilitation programmesChangesChanges toto bodybody inin COPDCOPD Ventilatory limitation Gas exchange limitation Cardiac dysfunction Skeletal muscle dysfunction Respiratory muscle dysfunctionVentilatoryVentilatory limitationlimitation Increased dead space ventilation Impa
28、ired gas exchange Increased ventilatory demands due to peripheralmuscle dysfunction Pathophysiology e.g.emphysema Delayed emptying dynamic hyperinflation increasedWOB increased respiratory muscle load increasedperception of respiratory discomfortGasGas exchangeexchange limitationlimitation Hypoxia I
29、ncreases pulmonary ventilationCardiacCardiac dysfunctiondysfunction Increase in RV afterload due to increased PVR Hypoxic vasoconstriction ErythrocytosisSkeletalSkeletal musclemuscle dysfunctiondysfunction Change in muscle fibre type Reduced capacity of oxidative enzymes Reduced number of capillarie
30、s Inflammatory state Nutrition/body massSkeletalSkeletal musclemuscle changeschanges Average reduction in quadriceps strength isdecreased by 20-30%in moderate to severe COPD Reduction in the proportion of type I muscle fibresand an increase in the proportion of type II fibrescompared to age matched
31、normal subjects Reduction in capillary to fibre ratio and peakoxygen consumption.SkeletalSkeletal musclemuscle contcont Reduction in oxidative enzyme capacity andincreased blood lactate levels at lower work ratescompared to normal subjects Due to intrinsic factors which result in earlyactivation of
32、anaerobic glycolysis Prolonged periods of under nutrition which resultsin a reduction in strength and enduranceInIn conclusionconclusion Musculoskeletal changes suggest that patients withCOPD present with muscle weakness,and fatigue(with exercise)more quickly than their normalcounterparts.SkeletalSk
33、eletal MuscleMuscle inin COPDCOPDType II 57%Jobin J,et al.J Cardiopulmonary Rehab 1998.Bernard et al.AJRCCM 1998.Dyspnoea and legfatigue31%Leg fatigue43%Dyspnoea26%LimitingLimiting symptomssymptoms inin COPDCOPD patientspatients atat peakpeak exerciseexerciseKillian KJ,et al.1992.RespiratoryRespirat
34、ory musclemuscle dysfunctiondysfunction Compromised functional inspiratory muscle strength Compromised inspiratory muscle enduranceWhatWhat shouldshould PRPR include?include?Strength training Endurance training Education Social and psychosocial factorsExerciseExercise The BTS statement on pulmonary
35、rehabilitation (BTS,2001)recommends that pulmonary rehabilitation mustcontain aerobic exercise,and may contain upper andlower limb strength exercises.The BTS alsorecommend that exercise frequency should be threetimes a week for 30 minutes.Intensity should beset at least 60%of maximum oxygen uptake,t
36、his canbe derived from an exercise capacity test.EnduranceEndurance TrainingTraining COPD patients participating in endurance traininghad lower peak work rates and oxygen uptake thannormal subjects;however these variables improvedwith training.Subjects with COPD showed different physiologicaladaptat
37、ions to endurance training than the normalsubjects COPD subjects showed an increase in peak oxygenextraction but no significant change in heart rate,ventilation or oxygen delivery.This suggests changes from training take place at askeletal muscle level rather than a change inventilatory response to
38、exercise.Sala et al.,1999ATS/ERSATS/ERS StatementStatement onon PRPR 20062006PRPR EducationEducationSoSo WhatWhat cancan exerciseexercise do?do?May improveExercise toleranceExertional dyspnoeaCardiovascular functionFatigueAbility to carry out ADLsMoodStrengthWhat do we do in Tower Hamlets?8 week rol
39、ling programme2 hoursTwice a weekFollowed by 8 week programme of maintenanceOnce a weekExercise-individual programme aimed at meeting clientspersonal goalStrengthEnduranceEducationMulti professionalCoping strategiesImprove knowledge of how lung disease affects youCup of tea!What do we do in Tower Ha
40、mlets?Pulmonary rehabilitation in 8 locations across the boroughClasses in leisure centres,hospitals,GP practices,social clubs,community centresBengali speaking rehab support workersTai chi classMulti-disciplinary teamHome programme for patients unable to attend local sitesPR classesStrength exercis
41、esEndurance exercisesDealing with an exacerbationRelaxation and stress managementMedications and how they workSmoking cessationSoSo whatwhat dodo wewe actuallyactually do?do?Patients referred by GPs,consultants/hospitalDrs,practice nurses,respiratory nursespecialists,physios.Initial assessment Suita
42、ble for PR medical history cardiovascular stability medical management optimised exercise capacity anxiety and depression quality of life Other questionnairesThenPatient and physiotherapist discuss goalsExercises tailored to patient to help meet goalExercise twice a week at PRExercise at least three
43、 times/weekHome exercise booklet and diaryReassessed at eight weeksWhat the clients say about PRIm able to walk for 300-400 yards without stopping.Ive beenable to go back to my hobby of song writing as I can sing againwhich I hadnt been able to do for several years.Male age 74Before I didnt do anyth
44、ing I just sat down,now I feel I reallywant to do the exercises.It has given me a new lease of life.Now I have more confidence going out,I go out more often tothe market and shops.Female age 70The future for PR in Tower HamletsChanges to referral process through“prescription pads”in GPsurgeriesLooki
45、ng at improving compliance&uptake of PRRe-wording of letters we useHow and where we do our initial assessments呼吸困难呼吸困难&生活能力：恶性循环生活能力：恶性循环呼吸功能障碍呼吸功能障碍畏惧运动畏惧运动呼吸困难呼吸困难中度运动后中度运动后呼吸困难呼吸困难轻度运动后轻度运动后*=卧床静养卧床静养,恐惧抑郁恐惧抑郁,依赖氧疗依赖氧疗.更加畏惧更加畏惧呼吸困难呼吸困难日常生活中日常生活中去适应增加去适应增加*身体去适应身体去适应患者有意识和无意识的调整运动患者有意识和无意识的调整运动运动训
46、练的内容包括运动训练的内容包括上肢肌力训练上肢肌力训练下肢肌力训练下肢肌力训练上肢耐力训练上肢耐力训练下肢耐力训练下肢耐力训练呼吸肌肌力训练呼吸肌肌力训练柔韧性和平衡训练柔韧性和平衡训练功能性功能性*有趣有趣*有意义有意义脑卒中患者会带来什么影响？脑卒中患者会带来什么影响？脑卒中患者脑卒中患者偏瘫偏瘫1.一侧肌肉受累一侧肌肉受累2.去适应作用去适应作用脑卒中患者对心肺功能带来怎样的影响？脑卒中患者对心肺功能带来怎样的影响？合并症合并症实践模式实践模式ICD-9-CM编码编码肺机能不全肺机能不全6F518.82骨关节炎骨关节炎4C，4D，4E，4F，4G，4H，4I，6B715外周血管疾病外周血
47、管疾病4C，4J，6B，6D，7A，7D，7E443糖尿病糖尿病4C，4J，5G，6A，6B，7A，7B250高血压高血压6B，6D402脑卒中患者心肺功能障碍康复要点？脑卒中患者心肺功能障碍康复要点？1.首要的角色是：意识到受限的心肺功能首要的角色是：意识到受限的心肺功能2.预防相关心肺并发症预防相关心肺并发症3.识别并干预合并的心肺危险因素识别并干预合并的心肺危险因素脑卒中患者常见合并症病理改变，实践模式和脑卒中患者常见合并症病理改变，实践模式和ICD-9-CM编码编码脑卒中患者心肺康复评估要点脑卒中患者心肺康复评估要点1.2.3.4.心肺联合运动测试心肺联合运动测试呼吸肌肌力和耐力测试呼
48、吸肌肌力和耐力测试肺功能测试肺功能测试胸廓活动度测试胸廓活动度测试测试时间（测试时间（min）率（率（mph或或rpm）负荷进阶负荷进阶心率（心率（bpm）跑步平板跑步平板8-120.5-3mph渐增或间歇渐增或间歇220-年龄年龄下肢功率计下肢功率计4-850rpm10W/stage高于平板高于平板10-15%四肢联动功率计四肢联动功率计 4-850rpm渐增或间歇渐增或间歇220-年龄年龄脑卒中患者运动测试推荐方案脑卒中患者运动测试推荐方案临床提示：临床提示：在运动测试的过程中，在每次负荷进阶时，应询问及比对患者主观报告的自觉疲劳在运动测试的过程中，在每次负荷进阶时，应询问及比对患者主观报
49、告的自觉疲劳伯格量表（伯格量表（0-10）因为卒中患者极易疲劳，可以采用间歇运动测试方案，即运动和信息时间因为卒中患者极易疲劳，可以采用间歇运动测试方案，即运动和信息时间2:1；下；下次递增负荷为上次的次递增负荷为上次的1.5倍倍脑卒中患者运动测试的补充方案脑卒中患者运动测试的补充方案 Macko RF,1997:使用悬吊全减重，使用悬吊全减重，NaughtonBalke或或modified Balke方案，方案，速度恒定，其速度约为正常同龄人的速度恒定，其速度约为正常同龄人的55-65%，以坡度提高为负荷进阶，测试时间，以坡度提高为负荷进阶，测试时间8-12分钟分钟 Birkett WA,1
50、998:单侧曲轴上肢运动方式，使用心率进行测试单侧曲轴上肢运动方式，使用心率进行测试 Mackay-Lyons MJ,2002:脑卒中急性期脑卒中急性期(1 month)，使用开放回路的肺功能计，使用开放回路的肺功能计在跑步平台上测试最大的步行能力，减重在跑步平台上测试最大的步行能力，减重15%Billinger et al,2008:全身悬吊踏阶测试全身悬吊踏阶测试Total-Body Recumbent Stepper Test脑卒中患者呼吸肌功能测试脑卒中患者呼吸肌功能测试评估内容：评估内容：呼吸肌肌力呼吸肌肌力、呼吸肌耐力呼吸肌耐力 和和 呼吸肌抗疲劳性呼吸肌抗疲劳性评估方法多种多样：
