Need for pulmonary rehab programme
Patients doing pulmonary rehabilitation exercisesDr A.K. Janmeja
The chronic obstructive pulmonary disease (COPD) currently ranks fourth as the cause for death. It may take the third position worldwide by 2020. Exercise intolerance resulting from breathlessness and fatigue is often the main symptom reported by COPD patients.

Patients doing pulmonary rehabilitation exercises

‘One World, One Home, One Heart’
Dr Ashit Syngle
Heart is perhaps the only body organ that has earned considerable fame and has come to symbolise many human emotions. From a poet to a novelist to lyricist, paeans have been sung about the mischief of the heart.

Health Notes



Need for pulmonary rehab programme
Dr A.K. Janmeja

The chronic obstructive pulmonary disease (COPD) currently ranks fourth as the cause for death. It may take the third position worldwide by 2020. Exercise intolerance resulting from breathlessness and fatigue is often the main symptom reported by COPD patients.

The degree of exercise intolerance is roughly proportionate to the severity of the disease, and is present in patients with a mild form of the disease too. The ultimate effect is the impaired quality of life — decreased activities and frequency of exacerbation. Although COPD primarily affects lung functions, the other commonest systemic manifestation is the dysfunction of the leg muscle involved with ambulation.

These defects tend to reduce the aerobic capacity which is manifested as the early onset of lactic acidosis. This causes fatigue very quickly in these patients as compared to healthy subjects. In fact, muscle fatigue is the primary factor limiting exercise tolerance rather than breathlessness in COPD patients. And the primary cause is muscle deconditioning which is due to sedentary living in COPD patients. The pulmonary rehabilitation programme specifically takes care of such systemic problems over and above the lung dysfunctioning.

How does the pulmonary rehabilitation programme work?

l The pulmonary rehabilitation programme (PRP) doesn’t directly improve lung functions or gas exchange; rather it optimises the functions of the other body systems so that the effect of the lung dysfunction is minimised.

l PRP exercise programmes improvise functions mainly by inducing changes in muscle biochemistry. As a result, a higher workload can be tolerated without appreciable lactic acidosis and this delays fatigue which directly enhances exercise tolerance.

l Exercise training lowers the ventilatory demand, resulting in the slowing of respiration at a given level of exercise. With a longer respiratory cycle, there is less dynamic hyper inflation and hence less breathlessness.

l Exercise programmes often result in the desensitisation of breathlessness by decreasing its perception for a given job. Factors responsible for this desensitisation include the anti-depressants’ effect of exercise, social interaction and distraction from breathlessness that occur during the exercise with a group of patients suffering from a common condition.

l The rehabilitation programme also incorporates education for a self-management strategy plus a partnership approach between patients and health workers. This self-management education ultimately reduces the burden of health care services/hospitalisation and thus economises on the cost significantly.

Many studies have demonstrated clear-cut benefits of the PRP on different fronts — exercise capacity, severity of breathlessness and the health-related quality of life. The domains like breathlessness, fatigue, emotional function and mastery — the patient’s feeling of control over the disease — also show a marked improvement. The reduction in depression/ anxiety, improvement in cognitive functions and self-sufficiency have also been proven with the use of the PRP.

Schedule and components

The PRP is a multi-disciplinary patient programme which can be delivered as OPD-based, home-based, community-based, and even in-patient settings. PRP centres generally have a coordinator, who is trained in nursing/respiratory therapy or physical therapy. An excellent inter-personal skill is of paramount importance for the programme coordinator since the primary task is to motivate people for something they may find unpleasant. A pulmonologist overseas the programme as an overall incharge.

Patients with the commonly advanced COPD are referred to for the PRP, but milder cases can also be benefited. Also, those with breathlessness disproportionate to their disease and those having leg fatigue symptoms can also be offered the programme. In general, the PRP is not recommended for patients who are unable to walk because of some orthopaedic/neurological problems or those with cardiac disease like unstable angina/recent myocardial infarction. Sometimes psychiatric problems preventing the patients from attending the treatment plan may act as a relative contra-indication.

Three directly supervised sessions per week, each lasting three-four hours, constitute the usual schedule for most patients. The duration of most programmes ranges from six to 12 weeks. The patients are enrolled in the PRP as depicted below:

1. Assessment: A clinical assessment by the doctor / rehabilitation coordinator is done prior to the induction in the programme. Also, re-evaluation at intervals to evaluate the patient’s progress towards individual exercise and educational goals are undertaken. This helps as a guide for the intensity of a prescribed exercise.

2. Exercise programme: Endurance exercise of the leg muscle is the main focus, with walking, stationery cycling and treadmill exercises. High-intensity regimens are generally preferred, with initial targets of at least 60 per cent of the maximum exercise tolerance, although a lower intensity exercise is also beneficial. Exercise intensity is gradually increased under the observation of the rehabilitation staff. A resistance exercise component is also often included; improved leg strength aids in some daily activities and may lessen the risk of a fall. Resistance training of the upper arm is also useful.

3. Drug therapy: Ancillary measures like optimal broncho-dilation are prudent.

4. Oxygen therapy: The supplemental oxygen during training sessions in patients without a substantial exercise desaturation reduces the ventilatory demand.

5. Education: Education is incorporated to improve the patients understanding of the disease. This includes smoking cessation, incorporation of exercise/physical activities at home, importance of treatment adherence, and awareness on early detection of exacerbation.

6. Psychological assistance: The psycho-social component-based guidance on the needs for individual patients as anxiety and depression are common in such patients.

7. Nutritional supplementation: COPD patients with cachexia characterised by involuntary weight loss and depletion of lean body mass have a very poor prognosis. Nutritional supplement is often offered to such patients. The weight loss strategy is recommended in obese patients.

The PRP has proved beneficial in reducing breathlessness, enhancing the functional capacity and improving the quality of life of COPD patients. The PRP is also recommended for symptomatic COPD patients under international standard guidelines. Currently, PRP programmes are not available freely in our country. The cost for a programme with an average duration of eight weeks in the US is around $ 2200 per participant. However, the cost would be much lesser in our country. One such centre has been started at Government Medial College and Hospital, Chandigarh. The PRP programme in our country would go a long way in achieving the optimal goal of the holistic care for COPD and other respiratory patients.

The writer is Head, Pulmonary Medicine, Government Medical College and Hospital, Sector 32, Chandigarh.


‘One World, One Home, One Heart’
Dr Ashit Syngle

Heart is perhaps the only body organ that has earned considerable fame and has come to symbolise many human emotions. From a poet to a novelist to lyricist, paeans have been sung about the mischief of the heart.

Have a heart for life. Look after your heart so you can live better and longer. The younger you start, the better, but it is never too late to begin. On this World Heart Day (Sept 29), we challenge you to take charge of your family’s heart health and become your home’s advocate for heart-healthy living. This year is the eleventh year of the event and the theme this year is “One World, One Home, One Heart”.

One World

Cardiovascular disease causes 29 per cent of all deaths globally each year, making it the world’s number one killer. Cardiovascular disease is also the number one killer of women worldwide — a fact that women need to know. Each year over 9.1 million women globally die of heart disease and stroke. This is more than the total number of women who die from all cancers, tuberculosis, HIV/AIDS and malaria combined.

One Home

Take charge of your family’s heart health and become your home’s advocate for heart-healthy living. Four simple actions have been identified to help you and your family to avoid cardiovascular disease:

1. Ban smoking from home

Stop smoking tobacco in the home to improve your own and your children’s heart health. Stopping tobacco use can reduce your risk of cardiovascular disease significantly, no matter how long you have smoked.

2. Stock your home with healthy food options

A diet high in saturated fat increases the risk of heart disease and stroke. A healthy diet low in saturated fats (ghee, butter, etc) and salt but high in fruits and vegetables helps. Avoid processed foods.

3. Get moving

Physical inactivity increases the risk of heart disease and stroke by 50%. At the moment at least 60% of the world’s population fails to achieve the minimum recommendation of 30 minutes moderate physical activity daily — 60 minutes for children.

l Families should limit the amount of time spent in front of the TV or computer to less than two hours per day

l Organise outdoor activities for the family, such as cycling or hiking trips, or simply playing in the garden

l When possible, instead of using the car, take your bicycle or walk from home to your destination

Regular physical exercise adds not only years to life but also life to years.

4. Know your numbers

l Visit your doctor who can measure your blood pressure, cholesterol and blood sugar, together with body mass index (BMI).

l Once you know your overall cardiovascular disease risk, you can develop a specific plan of action to improve your heart health. Make this action plan clearly visible in your home as a reminder!

One Heart

However, not all heart events are preventable. It is, therefore, important to know what action to take should a heart attack or stroke occur at home. If you suspect a family member of having a heart attack or stroke, seek medical help immediately.

Over 70 per cent of all cardiac and breathing emergencies occur in the home when a family member is present and available to help a victim.

Learn the signs and symptoms of a heart attack or stroke

Warning signs of heart attack

l Chest discomfort, including squeezing or pain in the centre of the chest between the breasts or behind the breastbone

l Discomfort and/or pain spreading to other areas of the upper body such as one or both arms, the back, neck, jaw or stomach

l Shortness of breath with or without chest discomfort

Other signs include: unexplained weakness or fatigue, anxiety or unusual nervousness, indigestion or gas-like pain, breaking out in a cold sweat, nausea, vomiting, light-headedness and collapse

The writer is Senior Consultant Physician & Rheumatologist, Fortis Multispeciality Hospital, Mohali.


Health Notes
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Laughter Yoga is all the rage with Vietnam’s fitness fanatics

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Why stress gets the better of women, not men

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Eating veggies and fruits cuts the risk of certain bowel cancers

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