醫(yī)學(xué)肺康復(fù)詳解專業(yè)知識(shí)講座專題課件

肺康復(fù)詳解專業(yè)知識(shí)講座SkeletalMuscleinCOPDJobinJ,etal.JCardiopulmonaryRehab1998.Bernardetal.AJRCCM1998.TypeII57%LimitingsymptomsinCOPDpatientsatpeakexerciseDyspnoea26%Dyspnoeaandlegfatigue31%Legfatigue43%KillianKJ,etal.1992.ATS/ERSStatementonPR2006ATS/ERSStatementonPR2006EvidenceforPREvidence(levella)·Improvementsinexercisetolerance·Reductioninthesensationofdyspnoea·Improvementinhealthrelatedqualityoflife(HRQoL).Evidence(levellb)·Improvementinperipheralmusclestrengthandmass·ReductionsinnumberofdaysspentinhospitalEvidence(levellla)or(levelllb)·Improvementintheabilitytoperformroutineactivitiesofdailyliving·Reductionsinexacerbations·Reductioninanxietyanddepression·Improvementsinexercisetolerancemaintainedbetween6–12monthsEffectofTherapy-DoesNotimprovelungmechanicsorgasexchange,butoptimizesotherbodysystems*PulmonaryRehabilitationHistoricalPerspective1951:DrBarachrecommendedphysicalreconditioningforCOPDpatientsWalkwithoutbecomingdyspneicBarachwasignored;O2therapy&bedrestprescribedSkeletalmuscledeteriorationFatigue&weaknessIncreaseddyspneaHomebound,roombound,bedbound1962:PierceconfirmedBarachPiercefoundthatexercisingCOPDpatientsDecreasedpulseDecreasedrespiratoryratesDecreasedminuteventilationDecreasedCO2productionImprovedpulmonaryfunction教育及心理行為干預(yù)舊指南將心理、行為和教育一并納入COPD患者的肺康復(fù)方案中，而新指南對(duì)教育和心理行為干預(yù)分別進(jìn)行闡述：(1)教育干預(yù)：由于在綜合肺康復(fù)方案中均包含教育的內(nèi)容，因此很難區(qū)分教育干預(yù)的獲益大小，而且教育是患者積極參與肺康復(fù)和堅(jiān)持健康行為的保證，也是完成肺康復(fù)的保證，所以新指南仍指出教育應(yīng)該是肺康復(fù)不可分割的一部分。教育應(yīng)該包含協(xié)作性自我管理內(nèi)容和疾病惡化加重的預(yù)防及治療信息(推薦級(jí)別1B級(jí))。(2)心理行為干預(yù)：新指南對(duì)于心理行為干預(yù)的推薦內(nèi)容與舊指南基本一致，但描述更為細(xì)致。已有的研究結(jié)果證明，COPD患者容易合并抑郁和焦慮，特別是COPD急性加重和有機(jī)械通氣經(jīng)歷的患者更容易產(chǎn)生抑郁和焦慮，希望我國的呼吸科醫(yī)生關(guān)注COPD患者的精神和心理問題，并為他們提供幫助。PREducation康復(fù)宣教

1．患者須了解自己的病情和自我管理的原則2．患者須了解影響呼吸功能的病因，讓患者學(xué)會(huì)最基本的、切實(shí)可行的康復(fù)訓(xùn)練方法3．康復(fù)教育應(yīng)當(dāng)形式多樣、生動(dòng)活潑應(yīng)注意將教育管理貫穿和結(jié)合于各種醫(yī)療活動(dòng)中，這樣符合患者的需求，效果會(huì)更好1．訓(xùn)練方案應(yīng)個(gè)體化2．選擇適宜環(huán)境訓(xùn)練3．鍛煉時(shí)或鍛煉后如出現(xiàn)疲勞、乏力、頭暈等，應(yīng)該及時(shí)就診4．臨床病情變化時(shí)務(wù)必及時(shí)調(diào)整方案5．訓(xùn)練適度6．酌情適當(dāng)吸氧呼吸訓(xùn)練主要注意事項(xiàng)

ExerciseTheBTSstatementonpulmonaryrehabilitation(BTS,2001)recommendsthatpulmonaryrehabilitationmustcontain：aerobicexercise,andmaycontainupperandlowerlimbstrengthexercises.TheBTSalsorecommendthatexercisefrequencyshouldbethreetimesaweekfor30minutes.Intensityshouldbesetatleast60%ofmaximumoxygenuptake,thiscanbederivedfromanexercisecapacitytest.

DiseaseProcessMedicationsWhat,Why,HowStressManagementRelaxationTechniquesEnergyConservationBenefitsofExerciseEducation促進(jìn)心理康復(fù)的放松訓(xùn)練

在肺部疾病患者中常可觀察到心理異常的癥狀和心理健康水平的降低，因此必須給予患者積極呼吸訓(xùn)練和良好的心理護(hù)理1．重視壓力、情緒管理和控制2．啟發(fā)性心理治療3．放松訓(xùn)練4．美化環(huán)境，創(chuàng)造氣氛，開展文娛活動(dòng)

Relaxationandstressmanagement康復(fù)訓(xùn)練

康復(fù)方案根據(jù)美國紐約心臟病學(xué)會(huì)（NYHA）和Goldman等人提出心功能分級(jí)方案制定患者的心功能訓(xùn)練方案。Ⅰ級(jí)：患者活動(dòng)量不受限制，可做代謝當(dāng)量METs≥7的運(yùn)動(dòng)。Ⅱ級(jí)：患者的體力活動(dòng)受到輕度的限制，可做代謝當(dāng)量5METs～7METs的運(yùn)動(dòng)，每周運(yùn)動(dòng)鍛煉3次～5次，每次10min～25min

。Ⅲ級(jí)：心臟病患者體力活動(dòng)明顯限制，可做代謝當(dāng)量2METs～5METs的運(yùn)動(dòng)，每周運(yùn)動(dòng)5次～6次，每次5min～10min，漸增至每次40min

。Ⅳ級(jí)：心臟病患者不能從事任何體力活動(dòng)。休息狀態(tài)下也出現(xiàn)心衰的癥狀，體力活動(dòng)后加重?？勺龃x當(dāng)量METs＜2的運(yùn)動(dòng)。StrengthtrainingEndurancetrainingEducationSocialandpsychosocialfactorsWhatshouldPRinclude?有氧訓(xùn)練

有氧運(yùn)動(dòng)指中等強(qiáng)度的大肌群、節(jié)律性、持續(xù)一定時(shí)間的、動(dòng)力性、周期性運(yùn)動(dòng)，以提高機(jī)體氧化代謝能力的訓(xùn)練方法。有氧運(yùn)動(dòng)的運(yùn)動(dòng)強(qiáng)度越大，可持續(xù)時(shí)間就越短：運(yùn)動(dòng)強(qiáng)度持續(xù)時(shí)間較高5min（50%有氧代謝）高15min（80%有氧代謝）中30min（90%有氧代謝）低強(qiáng)度（走）2小時(shí)以上（接近100%有氧代謝）BenefitsofExerciseImproveIndependenceReduceIsolationConsistentexercisereducessensitivitytobreathlessnessImprovesefficiencyofbreathingImprovesconfidence運(yùn)動(dòng)處方的要素運(yùn)動(dòng)處方的要素主要包括運(yùn)動(dòng)強(qiáng)度、頻率和持續(xù)時(shí)間。(1)有氧運(yùn)動(dòng)訓(xùn)練強(qiáng)度：新指南中的隨機(jī)對(duì)照研究結(jié)果證明，COPD患者下肢高強(qiáng)度訓(xùn)練比低強(qiáng)度訓(xùn)練能產(chǎn)生更大的生理學(xué)獲益(推薦級(jí)別為lB級(jí))，且低強(qiáng)度和高強(qiáng)度訓(xùn)練均產(chǎn)生臨床獲益(推薦級(jí)別lA級(jí))。目前大多數(shù)運(yùn)動(dòng)訓(xùn)練強(qiáng)度是用極量或次極量運(yùn)動(dòng)平板(Bruce或改良的Bruce方案)評(píng)定心肺運(yùn)動(dòng)功能，達(dá)到最大耗氧量20％-40％的運(yùn)動(dòng)量為低強(qiáng)度，60％-100％的運(yùn)動(dòng)量為高強(qiáng)度。國內(nèi)有關(guān)家庭肺康復(fù)的研究采用心率估算運(yùn)動(dòng)量，雖然心率和呼吸困難Borg評(píng)分與心肺運(yùn)動(dòng)試驗(yàn)有較好的相關(guān)性，但由于影響心率的因素較多因此建議臨床研究設(shè)計(jì)使用較為客觀的科學(xué)指標(biāo)。(2)肌肉力量訓(xùn)練強(qiáng)度：力量訓(xùn)練屬于無氧運(yùn)動(dòng)，能夠增加中、重度COPD患者的肌肉力量和質(zhì)量，可作為獨(dú)立的干預(yù)措施改善患者的生存質(zhì)量，因此，新指南推薦在肺康復(fù)方案中加入力量訓(xùn)練方案，推薦級(jí)別為lA級(jí)。運(yùn)動(dòng)類型

等張運(yùn)動(dòng)對(duì)心血管系統(tǒng)影響為增加前負(fù)荷。運(yùn)動(dòng)時(shí)心率加快，左室舒張期充盈完全，心肌收縮力增強(qiáng)，每搏量和心輸出量均增加，最大限度地調(diào)動(dòng)了心臟的儲(chǔ)備能力。運(yùn)動(dòng)時(shí)兒茶酚胺增加，有助于冠狀動(dòng)脈血流量增加，改善心肌血供。運(yùn)動(dòng)項(xiàng)目主要包括散步、步行、慢跑、騎自行車、游泳、上下樓梯、劃船和球類等。等長運(yùn)動(dòng)雖然會(huì)使心率加快，心輸出量增加，但心肌收縮速度下降，心臟射血時(shí)間延長，舒張壓升高明顯，外周阻力增高。因此提高了心臟后負(fù)荷，心臟病患者等長運(yùn)動(dòng)時(shí)，射血分?jǐn)?shù)下降，心臟收縮功能降低，又由于氧耗量過多，胸內(nèi)壓力升高，影響血液回流到心肺，具有一定危險(xiǎn)性。但尚有部分學(xué)者認(rèn)為，等長收縮可通過顯著增高舒張壓，提高冠狀動(dòng)脈灌注壓。等長運(yùn)動(dòng)包括舉重、啞鈴、負(fù)重登梯等。運(yùn)動(dòng)處方

運(yùn)動(dòng)處方按鍛煉對(duì)象，可分為兩類：治療性運(yùn)動(dòng)處方預(yù)防性運(yùn)動(dòng)處方按鍛煉器官系統(tǒng)也將運(yùn)動(dòng)處方分為兩類：心肺體療鍛煉運(yùn)動(dòng)處方，運(yùn)動(dòng)器官體療鍛煉運(yùn)動(dòng)處方

制定運(yùn)動(dòng)處方時(shí)必須根據(jù)個(gè)人健身鍛煉的不同目標(biāo)靈活掌握，根據(jù)個(gè)體對(duì)健身鍛煉的反應(yīng)和對(duì)運(yùn)動(dòng)的適應(yīng)情況進(jìn)行必要的修正注意事項(xiàng)

1．保證充分的準(zhǔn)備和結(jié)束活動(dòng)，防止發(fā)生運(yùn)動(dòng)損傷和心血管意外2．選擇適當(dāng)?shù)倪\(yùn)動(dòng)方式3．注意心血管反應(yīng)4．肌力訓(xùn)練與耐力運(yùn)動(dòng)可交互間隔實(shí)施Enduranceexercises運(yùn)動(dòng)訓(xùn)練包括(1)下肢運(yùn)動(dòng)訓(xùn)練：在舊指南中下肢運(yùn)動(dòng)訓(xùn)練的推薦證據(jù)為A級(jí)，新指南的證據(jù)來源于15個(gè)隨機(jī)對(duì)照研究，病例數(shù)達(dá)到1225例進(jìn)一步支持并強(qiáng)化了下肢運(yùn)動(dòng)訓(xùn)練是肺康復(fù)關(guān)鍵性核心內(nèi)容的觀點(diǎn)。因此新指南將下肢運(yùn)動(dòng)訓(xùn)練作為“COPD患者肺康復(fù)的強(qiáng)制性內(nèi)容，推薦級(jí)別為1A級(jí)(2)上肢運(yùn)動(dòng)訓(xùn)練：上肢運(yùn)動(dòng)訓(xùn)練可增加前臂運(yùn)動(dòng)能力，減少通氣需求，新近的研究結(jié)果表明，上肢無支撐耐力訓(xùn)練能顯著改善上肢運(yùn)動(dòng)耐力，上下肢聯(lián)合訓(xùn)練方案優(yōu)予單純下肢運(yùn)動(dòng)訓(xùn)練。因此，新指南將上肢運(yùn)動(dòng)訓(xùn)練的推薦級(jí)別由B級(jí)改為lA級(jí)。我國現(xiàn)階段許多肺康復(fù)研究在試驗(yàn)設(shè)計(jì)中均未納入運(yùn)動(dòng)訓(xùn)練，說明研究者對(duì)肺康復(fù)的理解還有偏差。肺康復(fù)方案中最具有循證醫(yī)學(xué)證據(jù)的就是運(yùn)動(dòng)療法，其他方法均應(yīng)建立在運(yùn)動(dòng)療法的基礎(chǔ)之上。運(yùn)動(dòng)程序有氧訓(xùn)練的運(yùn)動(dòng)過程應(yīng)分為準(zhǔn)備運(yùn)動(dòng)、訓(xùn)練運(yùn)動(dòng)和整理運(yùn)動(dòng)3部分準(zhǔn)備活動(dòng)：指有氧訓(xùn)練之前進(jìn)行的活動(dòng),防止因突然的運(yùn)動(dòng)應(yīng)激導(dǎo)致肌肉損傷和心血管意外。運(yùn)動(dòng)強(qiáng)度一般為訓(xùn)練運(yùn)動(dòng)時(shí)的運(yùn)動(dòng)強(qiáng)度，時(shí)間5min～10min，方式包括醫(yī)療體操、關(guān)節(jié)活動(dòng)、肌肉牽張、呼吸訓(xùn)練或小強(qiáng)度的有氧訓(xùn)練。訓(xùn)練活動(dòng)：指達(dá)到靶強(qiáng)度的訓(xùn)練一般為15min～40min，是有氧運(yùn)動(dòng)的核心部分。根據(jù)訓(xùn)練安排的特征可以分為持續(xù)訓(xùn)練、間斷訓(xùn)練和循環(huán)訓(xùn)練法。整理活動(dòng)：整理活動(dòng)指靶強(qiáng)度運(yùn)動(dòng)訓(xùn)練后進(jìn)行較低強(qiáng)度的訓(xùn)練，其運(yùn)動(dòng)強(qiáng)度、方法與準(zhǔn)備活動(dòng)相似，時(shí)間為20min～25min。運(yùn)動(dòng)處方的應(yīng)用

以力量練習(xí)為主，結(jié)合有氧運(yùn)動(dòng)與伸展練習(xí)；力量訓(xùn)練前后進(jìn)行有氧運(yùn)動(dòng)和伸展練習(xí)1．練習(xí)強(qiáng)度：重物重量以能連續(xù)完成12次～13次為宜；每個(gè)動(dòng)作完成3組～4組。2．練習(xí)時(shí)間：力量練習(xí)時(shí)間為30min左右，有氧練習(xí)和伸展練習(xí)時(shí)間分別為10min。3．練習(xí)頻率：3次/周，持續(xù)半年。

4．注意事項(xiàng)：（1）練習(xí)者在力量訓(xùn)練前必須進(jìn)行準(zhǔn)備活動(dòng)，以伸展練習(xí)為主。（2）力量練習(xí)中的每個(gè)動(dòng)作要慢速完成，完成后保持2秒再做下一個(gè),每組動(dòng)作結(jié)束后，休息1min～2min再進(jìn)行下一組練習(xí)。

呼吸醫(yī)療體操

第一節(jié)雙手輔助腹式呼吸

第二節(jié)坐位漸進(jìn)呼吸

第四節(jié)側(cè)彎壓迫式呼吸

第三節(jié)雙手配合交替呼吸

第五節(jié)節(jié)律呼吸

第六節(jié)雙下肢輔助加強(qiáng)呼吸

第七節(jié)牽拉胸廓呼吸

第八節(jié)調(diào)整自由呼吸

運(yùn)動(dòng)訓(xùn)練1、下肢訓(xùn)練（耐力訓(xùn)練）運(yùn)動(dòng)方式：行走、登梯、活動(dòng)平版、功率自行車、健身跑等運(yùn)動(dòng)強(qiáng)度：每次運(yùn)動(dòng)后心率至少增加20％—30％，并在停止運(yùn)動(dòng)后5—10分鐘恢復(fù)至安靜值；或至出現(xiàn)輕微呼吸短促為止。運(yùn)動(dòng)時(shí)間：10-45分鐘/次，每周2-5次x4-10周注意事項(xiàng)：準(zhǔn)備、訓(xùn)練、整理2、上肢訓(xùn)練宜用體操棒作高度超過肩部水平的各個(gè)方向越過中線的活動(dòng)，或作高過頭的上肢套圈練習(xí)等．還可作手持重物，開始0.5kg．以后漸增至2-3公斤，作高于肩部的各個(gè)方向活動(dòng)，每活動(dòng)l-2min，休息2—3min，每天2次。每次練習(xí)后以僅出現(xiàn)輕微的呼吸短促為度。上肢訓(xùn)練

手搖車訓(xùn)練

提重物訓(xùn)練

肩關(guān)節(jié)的旋轉(zhuǎn)訓(xùn)練每活動(dòng)1min～2min，休息2min～3min，每天2次，監(jiān)測以出現(xiàn)輕微的呼吸急促及上臂疲勞為度。通常采用有氧訓(xùn)練方法如走、慢跑、騎車、登山等。得到實(shí)際最大心率及最大METs值。運(yùn)動(dòng)訓(xùn)練頻率2次/周～5次/周，到靶強(qiáng)度運(yùn)動(dòng)時(shí)間為10min～45min，療程4周～10周。

下肢訓(xùn)練也應(yīng)包括力量訓(xùn)練，以循環(huán)抗阻訓(xùn)練為主。下肢訓(xùn)練ExerciseTraining:

Frequency,IntensityandDurationDailytoweekly(x3/week)10-45mins(?<20minsinsufficienttoelicitatrainingeffect)50%intensity(50%peakoxygenconsumption)uptomaximumOptimumdurationnotdeterminedbutusually4-10weeks(longercoursesshowgreatereffects)ExerciseTraining:Whichmusclegroups?LowerlimbtrainingimprovesexercisetolerancethoughnoeffectonmeasuredlungfunctionDOESN’THAVETOBEHITECH-corridortrainingcommonUpperlimbtrainingimprovesarmstrengthandreducesventilatorydemandRespiratorymuscletrainingmayinfluenceenduranceanddyspnoeabutevidenceisconflicting運(yùn)動(dòng)頻率

指每周運(yùn)動(dòng)的次數(shù)，一般3次/周～5次/周，或隔日一次即可。少于2次/周，常不能有效改善心肺機(jī)能，運(yùn)動(dòng)效果不佳。為增強(qiáng)耐力而訓(xùn)練時(shí)，可采用多次重復(fù)而運(yùn)動(dòng)強(qiáng)度較小的練習(xí)方法。運(yùn)動(dòng)強(qiáng)度和運(yùn)動(dòng)持續(xù)的時(shí)間是影響鍛煉效果的重要因素。運(yùn)動(dòng)持續(xù)的時(shí)間長短與運(yùn)動(dòng)強(qiáng)度呈反比，強(qiáng)度大，持續(xù)時(shí)間則可相應(yīng)縮短，強(qiáng)度小，運(yùn)動(dòng)時(shí)間可相應(yīng)延長。一般要求鍛煉時(shí)運(yùn)動(dòng)強(qiáng)度達(dá)到靶心率后，至少應(yīng)持續(xù)20min～30min以上。運(yùn)動(dòng)持續(xù)時(shí)間

在運(yùn)動(dòng)處方中常以靶心率（targetheartrate，THR）來控制運(yùn)動(dòng)強(qiáng)度。計(jì)算靶心率常用以下方法：（1）直接最大心率百分?jǐn)?shù)法：靶心率＝（220－年齡）×60％～90％（2）儲(chǔ)備心率法：

儲(chǔ)備心率＝最大心率（HRmax）－安靜時(shí)心率（HRrest）靶心率＝［（HRmax－HRrest）×0.50～0.85］+HRrest心率最大心率目前最流行的觀點(diǎn)是，有氧煅練的最適宜心率區(qū)間為最大心率的60～80%:

最適宜運(yùn)動(dòng)心率＝心率儲(chǔ)備X（60%-80%）+靜止心率.安靜時(shí)心率靶心率調(diào)整與監(jiān)護(hù)

患者在訓(xùn)練過程中沒有不良反應(yīng)，運(yùn)動(dòng)或活動(dòng)時(shí)心率增加＜10次/分，次日訓(xùn)練可以進(jìn)入下一階段。運(yùn)動(dòng)中心率增加在20次/分左右，則需要繼續(xù)同一級(jí)別的運(yùn)動(dòng)。心率增加超過20次/分，或出現(xiàn)任何不良反應(yīng)，則應(yīng)該退回到前一階段運(yùn)動(dòng)，甚至?xí)簳r(shí)停止運(yùn)動(dòng)訓(xùn)練。為了保證活動(dòng)的安全性，可以在醫(yī)學(xué)或心電監(jiān)護(hù)下開始所有的新活動(dòng)。合理運(yùn)動(dòng)的判斷1．運(yùn)動(dòng)強(qiáng)度指標(biāo)，下列情況提示運(yùn)動(dòng)強(qiáng)度過大：（1）不能完成運(yùn)動(dòng)。（2）活動(dòng)時(shí)因氣喘而不能自由交談。（3）運(yùn)動(dòng)后無力或惡心。2．運(yùn)動(dòng)量指標(biāo)，運(yùn)動(dòng)量過大會(huì)導(dǎo)致過度訓(xùn)練。過度訓(xùn)練的癥狀由自主神經(jīng)系統(tǒng)引起，表現(xiàn)為：（1）慢性持續(xù)性疲勞（2）運(yùn)動(dòng)當(dāng)日失眠（3）運(yùn)動(dòng)后持續(xù)性關(guān)節(jié)酸痛（4）運(yùn)動(dòng)次日清晨安靜心率突然出現(xiàn)明顯變快或變慢，或感覺不適（5）情緒改變

氧療和無創(chuàng)通氣新指南中增加了這方面的內(nèi)容。(1)氧療：對(duì)于運(yùn)動(dòng)期間血氧飽和度低于90％的COPD患者，在運(yùn)動(dòng)中吸氧可以增加其運(yùn)動(dòng)耐力，但對(duì)訓(xùn)練后的運(yùn)動(dòng)能力、最大氧耗量和6min步行距離、日常生活活動(dòng)能力評(píng)分等與對(duì)照組無明顯差別；對(duì)于運(yùn)動(dòng)期間血氧飽和度無明顯下降的患者，在運(yùn)動(dòng)中吸氧可以使其接受更高強(qiáng)度的訓(xùn)練，但對(duì)訓(xùn)練后的6min步行距離無明顯提高。根據(jù)患者運(yùn)動(dòng)時(shí)的主觀感受確定運(yùn)動(dòng)強(qiáng)度的方法，最初由瑞典GunnarBorg提出15個(gè)級(jí)別，1980年提出10級(jí)表。健康者RPE運(yùn)動(dòng)強(qiáng)度推薦為12～16級(jí)。實(shí)際日常運(yùn)動(dòng)訓(xùn)練中患者很難進(jìn)行心率和代謝當(dāng)量的自我監(jiān)測，所以自我感覺是比較適用的簡易判別指標(biāo)，特別適用于家庭和社區(qū)康復(fù)鍛煉。自感勞累分級(jí)表（ratingofperceivedexertion，RPE）十五級(jí)表十級(jí)表級(jí)別疲勞程度級(jí)別疲勞程度6

0沒有7非常輕0.5非常輕8

9很輕1很輕10

2輕11稍輕3中度12

13稍累4稍累14

15累5累16

6

17很累7很累18

8

19非常累9

20

10非常累，最累自感勞累分級(jí)表

BorgScaleofBreathlessnessToexercisecomfortablyyoushould:Keepyourshortnessofbreathratingbetween3and4.Keepoxygenlevelabove90%.TalkTest

Abletospeakinshortphrasesduringexercise.ScaleandSeverity0-NoBreathlessness1-VerySlight2-SlightBreathlessness3-Moderate4-SomewhatSevere5-SevereBreathlessness67-VerySevereBreathlessness89-VeryVerySevere10-MaximumScale營養(yǎng)治療營養(yǎng)治療：由于營養(yǎng)治療作為肺康復(fù)輔助手段的研究較少，因此，新指南未對(duì)此給出推薦意見。但營養(yǎng)問題是個(gè)體化治療方案的一部分，特別是對(duì)于合并糖尿病、代謝綜合征和營養(yǎng)不良的COPD患者，則更有其實(shí)際意義，應(yīng)該引起重視。DieticianAssessnutritionalstatusAlterdiettomaximizenutritionConsiderliberalizingthedietRecreationtherapistAssessleisureskillsandinterestsInvolvepatientsinrecreationalactivitiestomaintainsocialrolesExercise(Activity)PrescriptionforOlderAdults

Strength:UseIt&LoseLessofitLossesSedentarypeopleloselargeamountsofmusclemass(20-40%)6%perdecadelossofLeanBodyMass(LBM)GainsLeanbodymassincreases1-3kgResistancetrainingimprovesstrengthbyarangeof40-150%Musclefiberarea10-30%AerobicActivityISNOTsufficienttostopthisloss!BOTTOMLINES:MUSCLESTRENGTHENINGEXERCISESREQUIREDMUSTINCLUDEBALANCE+FLEXIBILITYINOLDERADULTSFEWERFALLS,FRACTURES,DISUSE,FRAILTYANDSARCOPENIAExercise(Activity)PrescriptionforOlderAdults

AlittlemoreaboutbalanceStaticDynamicIntensity=sensoryortimeMobilityAidsCrutches SupportsfullbodyweightOptions:underarm/forearmFitting:2inchesundershoulder;donotleanarmpitoncrutchContraindications:armweakness,shoulderarthritis,cognitiveimpairmentProblems:neuropathy,shoulderpain,difficulttolearntouseWheelchairSupportsfullbodyweightOptions:manual/motorized;accessories;lowertogroundorone-sideddrive(hemi-chair);racing,handcycleFitting:1-1.5inchesaroundhipsandunderknees;footplatesclearfloorby1-2inches;armrestatelbowheight;removablefootrestsandarmrestsContraindications:unabletosit,orabletowalksafelyProblems:deconditioning,contractures,pressuresoresMobilityAidsCaneSupports15-20%ofweightOptions:singlepoint,quadorhemi-caneSideoppositeaffectedlimbFittedtoulnarstyloidContraindicationsArmweakness,moderatetoseveregaitorbalancedeficitPotentialproblem:inadequatesupportMobilityAideWalkerSupports~30%ofweightOptions:4post,2wheel/2post,3wheel,4wheel,4wheelwithseatandhandbrakes(Rollator),4wheelwithsafetybarsandslingseat(MerryWalker),forearmsupportsFittedtoulnarstyloidContraindications:Environmentalhazards,severearmandgaitweaknessProblem:slowsgait,maneuverabilityWhorequiresPR?Itinvolveshandlingthepatientwhohasundergoneaheartorlungsurgeryandalsoformaintenanceofpatientssufferingthefollowingconditions:PneumoniaBronchiectasis(COPD)CysticfibrosisAsthmaCardiacbypasssurgeryAtelectasisLungabscessInterstitiallungdiseaseAimsofPR:ItisimportanttodoPRwhensufferingfromanyoftheabovelistedconditionsbecausetheaimofPRistomaintainbronchialhygieneintermsof:mobilizingandlooseningthesputuminthelungs

improvelungcapacitymaintaintheheart’sfunctionimprovingchestmobilityendurance&fitnesstrainingandimprovingqualityoflifeAphysiotherapistalsoplaysanimportantroleinthemultidisciplinaryteamof

ICU.Rehabisimportanttopreventthede-conditioningandweakness

duetoimmobilityintheICU,improveoxygenation,preventpulmonarycomplicationslikelungcollapse.WhatdoesPRconsistof?CPTconsistsofexternalmanualmanoeuvreslike：chestpercussionandvibration,huffing&coughingtechniques,patientpositioning,posturaldrainage,deepbreathingexercises,activecycleofbreathingtechnique(ACBT),thoracicexpansionexercises,spirometer,endurance&fitnesstraining.Percussion&vibration–Thepatientispositionedinagravityassistedpositionandmanualclappingisdoneonthepatient’schestsoastoremovethesputumHuffing&coughing–Thesearetechniquestofurtherloosenthesecretions.Huffingisaminorformofcoughinginwhichpatientfillsairinhislungsandthenbreatheoutsayinga“huh”.Thisisthenfollowedbycoughingtoremovethesputumout.Posturaldrainage–Thisinvolvestheadoptionofdifferentpositionswhichwillassistforthesputumtocomeout.Fordifferentsectionsofthelungthepatientispositionedindifferentpositions.Deepbreathingexercises–Thesearetheexercisestoimprovethelungfunction.Thisinvolvesdifferenttypesofbreathinglike“pursed-lipbreathing”,“diaphragmaticbreathing”whichhelpsthebronchiolestoexpandforbetterairexchange.Activecycleofbreathingtechnique(ACBT)Thisisaspecializedtechniquewhichinvolvesacycleof–breathingcontrol,deepbreathing&huffing.Breathingcontrolisgentlebreathingjusttorelaxtheairways.Deepbreathingisexpandingyourribcagewhileyouinhaleandemptyingtheribcagewhileyouexhale.

Thepicturebelowshowsthecycleofdoingit.Thoracicexpansionexercises–Theseareexercisestoimprovethemobilityandexpansionofthechestwhichultimatelyhelpsforbetterair–entryintothelungs.Theyinvolveacombinationofdeepbreathingandupperlimbsmovementstoenhancetheribcageexpansion.TheseexercisesarefurtheradvancedbytheusageofTherabandsorweightstostartwithresistancetrainingfortheupperbody.

Spirometer–Itisadeviceusedtoperformdeepbreathingexercises.Theadvantageofitisthatitgivesavisualfeedbackoftheperformancetothepatientandmotivatestoperformbetter.Endurance&Fitnesstraining–Itisanimportantpartofrehabastheperson’sfitnesslevelsreducetoasignificantlevelafterhavingaheart/lungissue.Fitnesstraininginvolvesincreasingtheactivitieslikewalking,staticcycling.Endurancetrainingistotrainyourheart/lungstoperformanactivityforaprolongedamountoftimesothatyoucancarryoutyourroutineactivitieswithoutfeelingtired,giddy,orfallingshortofbreath.AtPhysioRehab

weareallexperiencedandskilledtodealwiththeabovementionedconditionsandperformthetechniquesforyourbetterment.ChangestobodyinCOPDVentilatorylimitationGasexchangelimitationCardiacdysfunctionSkeletalmuscledysfunctionRespiratorymuscledysfunctionHypoxiaIncreasespulmonaryventilationIncreaseinRVafterloadduetoincreasedPVRHypoxicvasoconstrictionErythrocytosisChangeinmusclefibretypeReducedcapacityofoxidativeenzymesReducednumberofcapillariesInflammatorystateNutrition/bodymassAveragereductioninquadricepsstrengthisdecreasedby20-30%inmoderatetosevereCOPDReductionintheproportionoftypeImusclefibresandanincreaseintheproportionoftypeIIfibrescomparedtoagematchednormalsubjectsReductionincapillarytofibreratioandpeakoxygenconsumption.Reductioninoxidativeenzymecapacityandincreasedbloodlactatelevelsatlowerworkratescomparedtonormalsubjects

DuetointrinsicfactorswhichresultinearlyactivationofanaerobicglycolysisProlongedperiodsofundernutritionwhichresultsinareductioninstrengthandenduranceMusculoskeletalchangessuggestthatpatientswithCOPDpresentwithmuscleweakness,andfatigue(withexercise)morequicklythantheirnormalcounterparts.Airtrappinglinks

pathophysiologyandpatientcenteredoutcomesinCOPDAirtrappingHyperinflationAirflowobstructionPoorhealth-relatedqualityoflifeActivitylimitationDyspneaPatientCenteredOutcomesAnxietyTachypnea

VentilatoryrequirementDeconditioningCOPD

HypoxemiaExacerbationsCooperCB.AmJMed2006;119(10A):S21-S31.ChronicrespiratorydiseasePulmonaryphsiologicalabnormalityPulmonaryRehabilitation

BenefitsinCOPDImprovesexercisecapacity-EvidenceAImprovesperceivedbreathlessness-EvidenceAImprovesqualityoflife–EvidenceAReduceshospitalizationsandLOS–EvidenceAReducesanxietyanddepression–EvidenceAUBEimprovesarmfunction–EvidenceBBenefitsextendbeyondtrainingperiod–EvidenceBImprovessurvival–EvidenceBCOPDpatientsparticipatinginendurancetraininghadlowerpeakworkratesandoxygenuptakethannormalsubjects;howeverthesevariablesimprovedwithtraining.SubjectswithCOPDshoweddifferentphysiologicaladaptationstoendurancetrainingthanthenormalsubjectsCOPDsubjectsshowedanincreaseinpeakoxygenextractionbutnosignificantchangeinheartrate,ventilationoroxygendelivery.Thissuggestschangesfromtrainingtakeplaceataskeletalmusclelevelratherthanachangeinventilatoryresponsetoexercise.EnduranceTrainingEduca-tionPsyco-socialsupportGeneralexercisetrainingSelectedmuscletrainingChestphysio-therapyOccupa-tionaltherapyNutritionalinter-ventionCOPD++++++++++++++Asthma+++++++++CF&bronchiect.+++++++(*)++(*)++++++Chestwalldisor.+++Neuromusc.dis++++Respirsleepdis++++++InterstlungdisPre-postsurgery++++++++++++++Tracheostompat++++++++MaincomponentsofPRprogrammes

DonnerCF,DecramerM.PulmonaryRehabilitationERJMonograph,2000:13:132-142(+):Noevidence,(++):Fewevidences,(+++):Goodevidence,(*):BeforetransplantationPulmonaryRehabilitationCommonPhysiologicalParametersMeasuredDuringExerciseEvaluationBloodpressureHeartrateECGRespiratoryrateArterialbloodgases(ABGs)/O2saturationMaximumventilation(VEmax)O2consumption(eitherabsoluteVO2orMETS,themetabolicequivalentofenergeyexpenditure)CO2production(VCO2)Respiratoryquotient(RQ)O2pulsePulmonaryRehabilitationIntroductionandwelcome,programorientationRespiratorystructure,function,andpathologyBreathingcontrolmethodsRelaxationandstressmanagementProperexercisetechniquesandpersonalroutinesMethodstoadsecretionclearance(bronchialhygiene)HomeoxygenandaerosoltherapyMedications:theiruseandabuseMedications:useofMDIsandspacersDietaryguidelinesandgoodnutritionRecreationandvocationalcounselingActivitiesofdailylivingFollow-upplanningandprogramevaluationGraduationPulmonaryRehabilitationPROGRAMOBJECTIVESDevelopmentofdiaphragmaticbreathingskillsDevelopmentofstressmanagementandrelaxationtechniquesInvolvementinadailyphysicalexerciseregimentoconditionbothskeletalandrespiratory-relatedmusclesAdherencetoproperhygiene,diet,andnutritionProperuseofmedicatio