PULMONARY
REHABILITATION
Pulmonary Rehabilitation in
QEH started on April 2005 due to increasing number of
pulmonary cases that were referred to the Physiotherapy
department. This programme is called 'Preventive Medicine';
that is to prevent or reduce recurrent admissions due to
pulmonary problem. The Head of The Physiotherapy Department
is Haji Jumat bin Pani and the Pulmonary Rehabilitation
Physiotherapist is Ms Tracy Lojimin. Tracy spent one month
at UKM Medical Centre in September 2006 to learn pulmonary
rehabilitation.
Physiotherapy Mission
Giving Physiotherapy services
in term of assessment, advice, plan of treatment, treatment
and preventive advice comprehensively and with
evidence-based practice. This is to achieve a high standard
of care and medical services which are multidimensional to
upgrade the quality of life of patients and their families.
Physiotherapy
Objectives
- To achieve/maintain patients' optimal or maximal
physical ability in their houses and community
environment.
- To control and reduce respiratory symptoms especially
dyspnoea and fatigue
- To improve exercise tolerance
- To improve physical functional capacity
- To improve Quality of Life
- To prevent readmission of patients and also to reduce
the length of stay in hospital
Patient's Criteria
Patient with COAD (Chronic
Obstructive Lung Disease), Asthma, Bronchiectasis and other
chronic lung disease. The patients also need to be actively
involved in this program with full support from their
family. The patient must be referred by doctors and
physiotherapists.
The Service
Programme
- Individual therapy
- Group therapy
Length of programme : 8
weeks
Intensity of programme : 2
sessions per week (Tuesday and Thursday)
Duration : 40 – 60 minutes per
session
Time : 10am – 12pm
The programme consists of:
- Warming up and stretching and also warming down
(breathing exercises, upper and lower limb exercises)
- Circuit training exercises ( stationary bicycle,
dumbbell (upper limb resistance exercises), steps, brisk
walking and treadmill)
PULMONARY PHYSIOLOGY UNIT
SPIROMETRY
Introduction
The flow volume
curve is used to obtain information that can be useful in
the diagnosis of various forms of lung disease such as
airflow obstruction, pulmonary fibrosis and muscle weakness,
assessment of disability, monitoring the progress of disease
and evaluating the effectiveness of treatment.
The
spirometer is used to measure the flow volume curve. A
number of measurements are made with the
spirometer:
1. Forced Vital Capacity (FVC) - is the
maximal volume of air exhaled from maximal inspiration
(Total lung capacity - TLC) to the lowest achievable lung
volume (Residual Volume - RV) with a maximally forced
expiratory effort. It is determined by the power of
respiratory muscles, the elastic properties of the chest
wall and the lung parenchyma, and the size and patency of
the airways at low lung volumes.
2. Forced Expiratory
Volume at 1 second (FEV1) - is the volume exhaled in the
first second of a FVC manoeuvre. It is determined by the
elastic recoil of the lungs and the resistance of the
intra-thoracic airways.
3. FEV1/FVC - is the ratio of
the FEV1 to the FVC, expressed as a percentage; it is used
to normalise FEV1 for lung size.
Picture 1. 2 technologists who perform various
tests in the pulmonary physiology lab Picture 2. A patient
inside the body plethysmograph for lung volume measurement
GENERAL RESPIRATORY FUNCTION TEST
Introduction:
The 'General
Respiratory Function' test consists of a group of tests that
together provide the basic assessment of the respiratory
function of patients referred to the Department for
evaluation.
Definition:
General Respiratory Function test
comprises the following measurements:
1. Lung Volumes
including total lung capacity (TLC), residual volume (RV)
and vital capacity (VC) using either the plethysmographic or multiple breath nitrogen washout techniques.
2. Maximum expiratory flow
volume curves (the relationship between absolute lung volume
and maximum expiratory flow) during a forced expiration from
total lung capacity to residual volume performed before and
after bronchodilator.
3. The uniformity of the
distribution of ventilation within the lung using the single or multiple
breath nitrogen washout techniques.
4. Single breath
gas transfer for carbon monoxide and gas transfer corrected
for the 'effective' alveolar volume at which the measurement
was made. Gas transfer = Tl; Gas transfer/alveolar volume =
Tl/VA.
5. Resting arterial oxygen saturation
(SaO2).
6. Respiratory muscle strength measured as
the maximum mouth pressures able to be generated during
expiratory effort at TLC (MEP) and during inspiratory effort
at RV (MIP). These are routinely measured on patients when
the measured TLC is lower than the predicted TLC by one
standard deviation or
more.
Rationale:
These tests
together help to define the function of the airways, the
alveoli and respiratory muscles. The individual measurements
are influenced by the function of both airways and alveoli,
and therefore are relatively insensitive and non-specific in
recognising particular disease entities and defining the
likely cause of any disability. For example, airflow
obstruction with reduction of maximum expiratory flow rates
may be due to airway disease or to emphysema. In both
circumstances maximum flows and FEV1 will be decreased.
However, in airway disease alone alveolar function is normal
and gas transfer will be normal or reduced in approximate
proportion to the degree of non-uniform ventilation. By contrast airflow obstruction with a reduced gas
transfer strongly suggests emphysema particularly if
associated with an increased total lung capacity indicating
increased pulmonary distensibility.
In the majority
of patients, the General Respiratory Function test alone
provides an adequate basis for defining the nature and
severity of the underlying disorder/s. Because the
measurements are highly repeatable and reflect the function
of airways and alveoli they provide a sensitive assessment
of progress with time and/or treatment. Where the nature of
an abnormality is uncertain the General Respiratory Function
test is complemented by performance of more specific tests.
For example where an individual has a reduced total lung
capacity and there is uncertainty as to whether this is due
to decreased pulmonary distensibility or to weak inspiratory
muscles, then measurements of lung and/or chest wall
mechanics are performed.
Interpretation:
The functions of
the respiratory system which determine the results of
General Respiratory Function test measurements and
therefore, the mechanisms of any abnormality, are defined
below:
Measurement
Determinants:
TLC :(a) Strength of
inspiratory muscles (b) Distensibility of lung and chest
wall
RV :(a) Strength of expiratory muscles (b) Airway
resistance (c) Distensibility of chest wall
VC: VC is the
volume exhaled between TLC and RV; it is therefore
determined by all of the factors which determine TLC and
RV
MEF's: (a) Elastic recoil pressure of the lung at each
volume between TLC and RV (b) Airway resistance (c)
Compliance of flow limiting airways
N2 Washout (Slope of
volume vs N2%): Distribution of time constants within the
lung and therefore the distribution of resistances of
airways and compliances of alveoli
Tl: (a) Amount of
haemoglobin in alveolar capillaries (b) The number of
alveoli (c) Thickness of the alveolar wall between alveolar
gas and pulmonary capillary blood i.e. diffusion (d)
Distribution of ventilation in relation to the distribution
of alveolar capillary blood volume
Tl/VA: Corrects Tl for
reduction of alveolar numbers, eg. atelectasis or uneven
ventilation with functional reduction of alveolar
numbers
SaO2: Adequacy of gas exchange at rest
MEP at
TLC: Strength of expiratory muscles
MIP at RV: Strength
of inspiratory muscles
METHACHOLINE BRONCHIAL PROVOCATION TEST
Aim:
In asthma, smooth muscle in the airways tends to react in an extremely sensitive fashion to various stimuli. One method of testing the degree of airway reactivity is by measuring the change in airway function in response to methacholine aerosol. The degree of reactivity correlates closely with the presence and severity of asthma.
Procedure:
Patient inhales increasing concentrations of methacholine aerosol delivered by a dosimeter. Serial spirometry is performed to observe a fall in FEV1. The test is terminated when FEV1 falls by 20% from the baseline. Bronchodilator is given if the test is positive to ensure FEV1 returns to near baseline before the patient goes home.
A patient undergoing methacholine bronchial provocation testing
EXERCISE
TESTING
Introduction:
The
exercise test is designed to quantify the exercise
performance of patients in which exercise is limited by
certain symptoms, such as shortness of breath. Quantitative
information is obtained regarding the following systems and
processes: ventilation and pulmonary gas exchange; central
and peripheral circulation; blood gas transport; and
peripheral gas exchange and metabolism.
Abnormalities
in an exercise test are likely to be helpful
in determining the following:
exercise-induced asthma
suitability for pulmonary resection in lung cancer
pulmonary fibrosis
pulmonary vascular
disease
dyspnoea - cause unclear
primary myocardial
disease
