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Management of respiratory diseases beyond drugs: Pulmonary Rehabilitation

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Shobha Shukla, Citizen News Service (CNS)

A very interesting and informative panel discussion on Pulmonary Rehabilitation (PR) of patients of respiratory diseases was held as part of the 20th National Conference on Environmental Sciences and Pulmonary Diseases (20th NESCON), organized by the Academy of Respiratory Medicine, under the auspices of Environmental Medical Association in Mumbai.

Pulmonary rehabilitation is an evidence-based multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic. It is based on a thorough patient assessment and integrated into the individualized treatment of the patient. It consists of patient-tailored therapies that include exercise training, education, and behavior change, and is designed to reduce symptoms, optimize functional status, increase participation in physical and social activities, improve the physical and psychological condition, and reduce healthcare costs with a view to improving overall quality of life.

These goals are achieved through patient and family education, exercise training, psychosocial interventions and assessment of outcomes. The interventions are geared towards individual problems of a patient and should be administered by a multidisciplinary team involving education, exercise, nutrition, and psychological support.

Dr Parvaiz Koul, Head of the Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, stressed upon the importance of PR in patients of COPD. Worldwide 400 million people are affected with COPD with an average prevalence of 10.1%. The estimated burden in India is 15 million people with a reported prevalence of 3.5%. Although it is the third most common cause of death it is under-diagnosed and under-treated and its impact is under-estimated. According to Dr Koul, "PR helps patients of COPD. They appear to benefit from exercise-training programmes at all stages of the disease. It results in improved exercise capacity, reduced perceived intensity of dyspnea, reduced hospitalization, reduced anxiety and depression, and improved upper-lung function. Both upper- and lower-extremity training should be utilized. Respiratory-muscle training can be considered in patients with respiratory-muscle weakness. However, patients with severe orthopaedic or neurological disorders limiting their mobility should be excluded from exercising."

"There are multiple settings for the PR programme--in the hospital outdoor patients, indoor patients, at home, and community-based. An important component of PR is education of the patient about breathing strategies, bronchial-hygiene techniques, proper use of medications (including oxygen), benefits of exercise, and eating right. They must also be educated about irritants such as tobacco smoking, and prevention/early treatment of respiratory exacerbations."

Dr Surya Kant, Professor and Head, Department of Pulmonary Medicine, King George's Medical University (KGMU), spoke passionately about PR in TB patients who had completed treatment. Quoting India's first Prime Minister Pandit Jawahar Lal Nehru (whose wife died of TB) he said that --whether we ourselves have escaped from the scourge of TB or not, there are probably very few families which have not had to do something with this dreaded disease.

He agreed that on successful completion of TB treatment the obvious expectations of the TB physician as well as patient are rapid clinical recovery, early bacteriological conversion, complete radiological clearance, and NO future complications. Unfortunately things do not work out this way for all. Dr Surya Kant rued that, "While patients with good response become asymptotic forever and there are no sequelae, those with poor responses have a lot of complications such as lung collapse, persistent cavity, post-tubercular obstructive disease, and recurrent respiratory infections, among others. In other words they become respiratorily crippled or handicapped. Such patients wonder why they are not able to lead a normal life although they have been declared cured. It is yet not known as to why there are these two different types of responses when the causative organism is the same and the treatment is also same."

The rehabilitation programme for the post-tubercular obstructive airway-disease patient is same as that for those with COPD. They also need psychosocial support and proper nutrition. Dr Surya Kant strongly favoured a law to consider such patients as respiratorily handicapped and extend them all the existing legal benefits for physically handicapped. They must get some vocational training for work conducive to their physical capacity.

Dr S Yuvarajan, Consultant Pulmonologist of Puducherry and Chennai, explained that IPF is characterized by an inexorable progression of interstitial fibrosis and worsening gas exchange leading to death from respiratory failure within five years of occurrence in the majority of patients. It is very difficult to diagnose IPF and there is no promising treatment for IPF till now. He said that, "People with chronic lung diseases are often caught in a vicious circle of deconditioning--their inactivity leads to muscle weakness, which leads to increased efforts to do work, decreased work capacity, and increased shortness of breath, and so more inactivity. The structure of an ideal PR programme for them consists of a minimum of twice-weekly supervised sessions in a hospital OPD."

Dr Salil Bhargava, Professor and Head, Department of Pulmonary Medicine, MGM Medical College, Indore, said that, "Rehabilitation is important in cardiothoracic and chest-related surgery. However, before starting, it is important to know of co-morbidities and associated illnesses like diabetes, coronary-artery disease, and COPD, among others. Patient education should cover all issues. Pre-operative and post-operative rehabilitation both are equally important. If we start the rehabilitation before surgery then outcomes are better in the long run. If the patient is trained before surgery then there is better cooperation from the patient due to establishment of a rapport and confidence building. In such cases post-operative exercises are learned easily, there are reduced cardio-pulmonary complications, and reduced duration of rehabilitation. Interventions include incentive spirometry, active range-of-motion exercises, general mobility exercises, teaching huffing and coughing techniques, and strengthening of muscles to be incised."

It was agreed by the experts that all patients of TB, COPD, and IPF should get pneumococcal and influenza vaccines as per a planned vaccination schedule. Even upper respiratory-tract infection incidence goes down after vaccination.

Experts were also of the view that there is no one size of PR that fits all the patients. Pulmonary-rehabilitation programmes must be tailored individually according to the patient's welfare and needs. But there are hardly any state-of-the-art pulmonary-rehabilitation centres in India that can assist patients with different needs. Also it is difficult for many health facilities to even procure good respiratory-exercise equipment, forget about having an inter-disciplinary team of dedicated professionals to address the issue. Then again, in India physiotherapists generally deal with orthopaedic problems and have no idea of unique needs and contexts of respiratory physiotherapy.

Dr Surya Kant rightly felt that, "We will have to find solutions that work in our local context. Chest physicians should use respiratory rehabilitation more and more. We must build and train our own team of nurses, social workers, dieticians, psychiatrists, physiotherapists, etc. We have to indigenously develop exercises and breathing practices that are suitable for our patients in our own context. Then only will we have better outcomes."

Shobha Shukla, Citizen News Service (CNS)
(The author is the Managing Editor of CNS. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on gender justice, childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org)

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