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Pulmonary Rehabilitation

Nyimas Fatimah
Overall function
 Movement of gases
 Gas exchange
 Transport of gas (oxygen and carbon dioxide)
 Diaphragm & Intercostal muscles
 Increases volume in thoracic cavity as muscles contract
 Volume of lungs increases
 Intrapulmonary pressure decreases (758 mm Hg)
 Muscles relax
 Volume of thoracic cavity decreases
 Volume of lungs decreases
 Intrapulmonary pressure increases (763 mm Hg)
 Forced expiration is active
 Improvement in cardiopulmonary function
 Prevention and treatment of complications
 Increased understanding of the disease
 Increased patient responsibility for self-care and compliance
with medical treatment
 Improvement in level of activity and quality of life, return to
 Improvement in exercise tolerance, symptom-limited oxygen
consumption, work output, mechanical efficiency, and vital
 Exercise increases arterial venous oxygen (AVO2) difference,
increasing oxygen extraction from arterial circulation
 Reduction in dyspnea and respiratory rate
 Improvement in general quality of life; decreased anxiety and
depression, improvement in Activities of Daily Living (ADLs)
 Improvement in ambulation capacity
 Decreased hospitalization rates
 Focus on conditioning peripheral musculature in order to improve
their efficiency and reduce stress on the heart and lungs
Obstructive Pulmonary Disease (OPD)
 Characterized by increased airway resistance due to
bronchospasm resulting in air trapping, low maximum
midexpiratory flow rate, and normal to increased compliance
(lung’s ability to stretch and expand)
 Impaired blood oxygenation secondary to perfusion-
ventilation mismatching. Gas exchange surface of the lung is
decreased as a result of air trapping. With decreased diffusion,
hypoxia is present with normal or increased ventilation
Restrictive Pulmonary Disease
 Impaired lung ventilation as a result of mechanical
dysfunction of the lungs or the chest wall, with respiratory
muscle dysfunction. Stiffness of the chest wall or the lung
tissue itself
 Hypercapnia precedes hypoxia, causing oxygenation
 Almost all lung volumes are decreased
 Evaluate Nutritional State
 Optimize Pharmacologic Treatments Prior to Starting
the Rehabilitation Program
 Train in Controlled Breathing Techniques
 Maintain an Adequate Airway (controlled cough and
huffing) and Secretion Management Program
(postural drainage with chest PT)
 Provide Therapeutic Exercises
 Instruct In Reconditioning Exercises
 Muscle Rest Periods Should Be Added to the Exercise
Controlled Breathing Techniques
(Obstructive Lung Disease)

1. Techniques to Improve Pulmonary Function

a. Diaphragmatic breathing
b. Segmental breathing

2. Techniques to Reduce Dyspnea and the Work of

Pursed-lip breathing
Diaphragmatic breathing
 Benefits: increased tidal volume, decreased functional
residual capacity, and increase in maximum oxygen uptake
 Method:
1. Patient uses the diaphragm, relaxes abdominal muscles during
2. Lying down, or at 15% to 25% head-down position, the
patient places one hand over the thorax below the clavicle to
stabilize the chest wall, and the other over the abdomen
3. The patient takes a deep breath, and expands the abdomen
using the diaphragm
4. Feedback of abdominal and rib cage movement is obtained
through hand placement
Segmental breathing
 Obstructions, such as tumors and mucous plugs, should
be cleared prior to practicing this technique
 Method:
1. The patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in
a segment of the lung.
2. As the clinician feels the local expansion, the hand resistance
is decreased to allow inhalation.
3. This facilitates the expansion of adjacent regions of the
thoracic cavity that may have decreased ventilation
Pursed-lip breathing
 Benefits: prevents air trapping due to small airway collapse
during exhalation and promotes greater gas exchange in the
alveoli. Increases TV, reduces dyspnea and work of breathing
in COPD patients.
 Method:
1. Patient inhales through the nose for a few seconds with the
mouth closed, then exhales slowly for 4–6 seconds through
pursed lips
2. By forming a wide, thin slit with the lips, the patient creates
an obstruction to exhalation, slowing the velocity of
exhalation and increasing mouth pressure
3. Expiration lasts 2–3 times as long as inspiration
Airway clearance techniques (1)
 Controlled cough
1. The patient assumes an upright sitting position, inhales
deeply, holds the breath for several seconds, contracts the
abdominal muscles (“bears down” increasing intrathoracic
pressure), then opens the glottis and rapidly and forcefully
exhales while contracting the abdominal muscles and leaning
slightly forward.
2. This is repeated two or three times and followed by normal
breaths for several minutes before attempting controlled
3. Coughing generates high expulsive forces promoting
secretion retention and may exacerbate air trapping; also
leads to fatigue if the cough is weak.
Airway clearance techniques (2)
 Huffing
1. following a deep inhalation, the patient attempts short,
frequent exhalations by contracting the abdominal
muscles and saying “ha, ha, ha”
2. The glottis remains open during huffing, and does not
increase intrathoracic pressure
 therefore, in COPD patients where airways can collapse.
This is a more efficient means of secretion removal
 Patient Education
 Keep A Good Nutritional State
 Instruct In Controlled Breathing Techniques
 Use Adequate Secretion-Management Techniques
(manual assisted cough with Chest PT and Postural
 Use Noninvasive Ventilation
Controlled Breathing Techniques
(Restrictive Lung Disease)

1. Glossopharyngeal breathing
2. Air stacking hyperinflations
Glossopharyngeal breathing
 This is a noninvasive method to support ventilation, and it can be used
in the event of ventilator equipment failure
 The patient takes a deep breath, and uses the pistoning action of the
tongue and pharyngeal muscles to project air boluses into the lungs.
 Rhythmic opening and closing of the vocal cords occurs with each air
 Each breath usually consists of 6 to 9 air boluses (or up to 65), with
each bolus consisting of 30 to 150 ml of air (usually 60 to 200 ml.)
 Requires intact oropharyngeal muscle strength, and the patient should
not be tracheostomized
Air stacking hyperinflations
 A program of air stacking hyperinflations 2 to 4 times a day
with progressively increasing volumes helps prevent
atelectasis and can benefit VC
 Regular maximal insufflations can be provided with manual
resuscitators, portable ventilators, and mechanical
 Amouthpiece may be used, or a nosepiece may be provided
for larger volumes and when patients have weak oral muscles
Chest Physiotherapy and Postural
 Penggunaan teknik yang diaplikasikan pada dinding dada dari
luar untuk memfasilitasi pembersihan sekret/mukus dari
saluran pernafasan, meningkatkan fungsi pernafasan dan
mengurangi komplikasi.
 Terdapat 2 metode dalam penanganan retensi mukus pada
saluran nafas bagian bawah :

1. Mengurangi produksi
sekret/mukus dengan obat-obatan.
2. Fasilitasi pembersihan mukus
dari saluran pernafasan.
 Hal-hal yang perlu diperhatikan :

Kemudahan dalam
Balance mukus, periksa evakuasi/membuang
dengan auskultasi. mukus.

Efek dari retensi mukus

terhadap fungsi paru dan Kontraindikasi pada
pertukaran udara. intervensi.
 Inhalasi nebulizer dengan normal saline, air, atau terbutaline :

Meningkatkan untuk
hidrasi sekresi
aktivitas getar silia meningkatkan
CPT & PD (Postural Drainage)
 Bertujuan untuk mengeluarkan mukus dari seluruh segmen
paru dengan mengandalkan gaya gravitasi.
 Meliputi 4 tahapan :
1. Memposisikan pasien sehingga mukus dapat mengalir dari
paru-paru ke saluran keluar yang akan mengakibatkan batuk
atau batuk yang distimulasi.
2. Perkusi, clapping secara ritmik pada dinding dada dengan
tangan yang membentuk sungkup pada seluruh lapangan
3. Vibrasi , gerakan vibrasi yang cepat pada dada saat pasien
melakukan ekspirasi yang panjang (biasanya pada saat pursed-
lip braething).
4. “Huffing and coughing” untuk mengeluarkan sekret diikuti
dengan relaxed control breathing.
 Pasien dengan penyakit paru akut atau kronis seperti
pneumonia, atelektasis, infeksi paru akut, PPOK.
 Paien dengan keadaan umumnya sangat lemah atau berusia
 Pasien dengan saluran nafas buatan.
 Pasien dengan penyakit paru yang berhubungan dengan
peningkatan produksi atau kekentalan lendir, seperti bronkitis
kronis atau fibrosis kistik.
 Paien dengan tirah baring lama.
 Pasien yang telah menerima anestesi umum atau pasien
dengan sayatan luka operasi yang menimbulkan nyeri yang
membatasi gerakan pernafasan dan proses batuk pasca
 Setiap pasien dengan ventilator jika dalam keadaan stabil dan
aman untuk dilakukan prosedur drainase postural.
 Emfisema subkutis
 Pemasangan pace maker yang baru
 Luka terbuka, luka bakar, infeksi kulit
 TB Paru
 Kontusi Paru
 Bronchospasme
 Nyeri dinding dada
 Osteoporosis
 Fraktur costae
 Hemoptysis
Kontraindikasi relatif
1. Kondisi akut yang tidak diobati, seperti :
 Edema paru berat
 Gagal jantung kongestif
 Efusi pleura berat
 Emboli paru
 Pneumothoraks
Kontraindikasi relatif
2. Ketidakstabilan sistem kardiopulmoner.
 Aritmia
 Hipertensi atau hipotensi berat
 Infark miokard baru
 Unstable angina
3. Pasca operasi bedah syaraf.
4. Hemoptisis berat
Efek samping/Komplikasi
 Perdarahan saluran nafas
 Fraktur costae
 Longgarkan pakaian yang ketat atau tebal.
 Siapkan tempat penampungan sputum dan tissue.
 Siapkan alas atau bantal yang memadai untuk posisi dan
kenyamanan pasien.
 Jelaskan prosedur tindakan kepada pasien.
 Mengedukasi pasien untuk bernafas dalam dan tehnik batuk
yang efektif.
 Jika sputum sangat banyak, minta pasien untuk batuk
beberapa kali atau dilakukan penghisapan endotrakeal
sebelum dilakukan prosedur.
 Mengatur alat-alat lain yang digunakan oleh pasien, seperti
kateter atau kabel EKG sehingga tidak terganggu pada saat
Postural Drainage
Postural Drainage
Postural Drainage
Postural Drainage
Postural Drainage
Postural Drainage
Postural Drainage
Postural Drainage
Inhalation Therapy
 Inhalation therapy is a term used for a variety of treatment
techniques, including drugs administered via inhalation. It
aims at targeting lung tissue, airway secretion and
microorganisms in upper, central and/or peripheral airways.
 However, drugs targeting systemic effects are used aiming at
deposition in the alveoli where it can be rapidly absorbed and
Drugs used in inhalation therapy
1. Oxygen therapy: The most common form of inhalation
therapy is the provision of oxygen
2. Anaesthetic agents
3. Beta2 agonists - Beta2 agonists are bronchodilators,
extensively used in treatment of asthma
4. Glucocorticoids - Inhaled glucocorticoids are the most
potent inhaled anti-inflammatory drugs currently available
5. Anticholinergic drugs - Ipratropium bromide (Atrovent) is
derivative of atropine that lacks its adverse side effects. Its
anticholinergic action also decreases mucous secretions
Thank you....