Editorial

T

Pulmonary Rehabilitation Dr. Raja Dhar, Consultant Repiratory Physician, Kolkata

he fact that Pulmonary Rehabilitation have reduced physical activity due to chronic Advantages of Pulmonary (PR) is an essential component in the breathlessness and fatigue. The subsequent rehabilitation: management of patients with chronic deconditioning is aggravated by system • Improves exercise tolerance respiratory disease can no longer be questioned. effects such as the different muscle, cardiac, • Reduces sensation of dyspnea Why is it so? Think of two different individuals. nutritional and psychosocial dysfunction. Sub- • Improves health related quality of life Person A, who is otherwise fit and well but optimal self management strategies add to the • Improves peripheral muscle strength leads a sedentary life style. He has a supra burden of disease (Lacasseu Y, Goldstein R). and mass • Reduces number of days spent in normal lung function on Spirometry but when hospital you ask him to climb 4 flights of stairs he feels • Low cost : benefit ratio breathless. At the other end of the spectrum • Improves ability to perform routine you have a champion who can climb Mount activities. Everest without Oxygen. Both have normal • Reduction in the rates of exacerbations lung function – how can one explain this • Reduces anxiety and depression difference in work performance and exercise tolerance? Enhanced work performance can However despite all these advantages there be attained by proper conditioning of the are big problems in the implementation of body with a well designed exercise program pulmonary rehabilitation in a developing that results in better utilization of oxygen nation like India. According to the latest and energy. It is this concept which has been census more than 70% of the Indian population incorporated in Pulmonary Rehabilitation resides in rural areas. However the facilities to improve exercise tolerance in respiratory of pulmonary rehabilitation even when disease. The most amount of evidence is available in tertiary care centers are located available with COPD and its role in other in the cities or in big teaching hospitals. The respiratory disorders is less well documented cost of rehabilitation is high to the tune of till date. As per American Thoracic Society about Rs 100,000. However the much touted (ATS) and European Respiratory Society Multidisciplinary (and evidence based) (ERS), Pulmonary rehabilitation is defined approach involving a Physician, a Psychiatrist, as “an evidenced based, multidisciplinary, a Physiotherapist and a Dietitian does multiply and comprehensive intervention for patients costs significantly. Even in tertiary care centers with chronic respiratory disease who are in cities with excellent infrastructure there symptomatic and often have decreased daily are a multitude of problems. Patients who life activities. Integrated into the need rehab are often unwilling individualized treatment of the to travel 2-3 times a week to Algorithm for Pulmonary Rehabilitation patients, Pulmonary Rehabilitation the center. Sometimes we are Initial assessment is designed to reduced symptoms, unable to convince our patients Clinical Evaluation, PFT, Dyspnea scores, optimize functional status, increase 6 Minute Walk Test, QoL assessment about the perceived benefits of participation and reduce health care rehabilitation. Often, there are cost for stabilizing or reversing competing commitments with Prescribing PR systemic manifestation of the rehabilitation which are perceived disease”. to be more ‘important’. For Nutritional The Cochrane review from Psychological Exercise training pulmonary rehabilitation to reach intervention intervention 2006 shows that Pulmonary • Lower limb the resource poor setting, we need • Upper Limb Rehabilitation results in an to come up with low cost models • Combined upper and lower limb training improvement in dyspnea and where adherence is relatively easy. Physical training fatigue, emotional function and There have now been studies • Breath retraining enhances the patients’ sense of which have shown that home based • Chest PT control over the disease condition. programs appear to be effective in This improvement is moderately improving exercise endurance, Outcome assessment large and clinically significant. sensation of dyspnea, and quality • Quality of Life Pulmonary rehabilitation helps of life in patient with COPD. • Dyspnea parameters you to come out of the “spiral of • Functional parameters >> page 2 disability”. Patients with COPD |Volume IV, Issue V, September-October 2014|RespiMirror 1

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Pulmonary Rehabilitation

These programs are easier to adhere to, and has much wider reach as far as the population base is concerned. If we think about rehabilitation in an Indian scenario we can describe it in three settings: 1. Rehabilitation in tertiary health care centers. 2. Outpatient based rehabilitation in a clinic or Nursing Home setting 3. Home rehabilitation Rehabilitation in tertiary health care centers in India would be no different, compared to what is available in European countries and is well documented in the text books and Journal articles. Let us try and think about outpatient/Clinic/Nursing Home based rehab. We can also consider Home rehab which is the easiest to implement.

ALGORITHM FOR Pulmonary Rehabilitation

Medical history and physical examination should be undertaken specifically looking at co-morbidities. More than 50% of patients with COPD will have one or more co-morbid condition and these should be identified and treated before we embark on Pulmonary Rehabilitation. Often this might not be immediately apparent and you might have to actively look for it. For a home based or OPD based rehabilitation program, the very least diagnostic tests required to start off would be recording of oximetry at rest and at walking, a formal 6 minute walk test, measurement of BMI, an ECG recording and the resting heart rate. Spirometry, Chest X-ray and Echocardiogram or more detailed assessment of exercise tolerance in the way of cardiopulmonary exercise testing should be done in tertiary care centers or left to the discretion of the Physician setting up Rehab. Specific questions should be asked regarding activities of daily living like bathing and washing, changing clothes etc. Leisure impairment should be specifically looked at. A formal PR assessment like an AQ 20 (less the time consuming should be used).

AQ 20: The Airways Questionnaire 20 (AQ-20) is specific for COPD patients and consists of 20 simple questions related to the impact of the disease on daily life. Each 2

question should be answered with “yes” or “no,” and 1 point is awarded for each yes. The final score ranges from 0 to 20 points; the higher the score, the worse the quality of life reported. This questionnaire was administered before and after the Home Based Pulmonary Rehabilitation. The initial assessment should also look at features of anxiety or depression and these should be addressed specifically if present. ‘The most important factor would be MOTIVATION from both the Pulmonologist and the Rehabilitation team. If you are able to convince your patient regarding the requirement and effectivity of pulmonary rehabilitation, it is then and only then that the patient is going to complete this program.’ Besides your own conviction and passion towards this intervention (which is of paramount importance), you would also need good communication skills and empathy to motivate your patient. The first interview should also carefully layout short and long term goals (for eg at the end of 12 weeks the patient should be able to ambulate 1 km over a period of 20 mins). It could also look at returning to community activities, ability to return to work and caring for the family. Chart on page 3 shows an outline of exercise training for a home/OPD based program. Overcoming challenges: Before you start a Pulmonary Rehabilitation program, you have to make sure that you identify a pool of eligible patients which will be able to sustain your center. Factors which facilitate referral to pulmonary rehabilitation include: • Increasing the awareness of the benefits of pulmonary rehabilitation through Media (News/ TV) Coverage Or Talks to lay people Or Distributing leaflets / books in clinic etc. • Integrating pulmonary rehabilitation into standard COPD care It might be worthwhile to start off with a home based program and then move on to an OPD or Nursing Home based program, once your first set of patients have reaped the benefits of having undergone home rehabilitation. It is this set of patients who could actually advertise your program better than anyone else can, and would ensure that you get a steady flow of patients for a more rigorous “observed” rehabilitation program in your center. Your center can be initiated with a mandatory set of equipments such as treadmill, pulse oximeter, oxygen support, heart rate monitoring with a polar heart monitor, a sphygmomanometer, stop watch, stairs or steps and then if possible a static cycle. You can then move on to a more ambitious program which includes multi-gym spirometer inspiratory muscle training device, rollator etc. You should ideally have access to psychiatrist, a physiotherapist, a nutritionist/ dietician and an occupational therapist. The physiotherapist is going to be the corner stone of your program and it is important that

RespiMirror|Volume IV, Issue V, September-October 2014|

AQ 20 Questionnaire Name: Date of birth: Do you live alone? ( ) Yes

( ) No

Personal care 1. Drying yourself after the shower ____ 2. Clothing the upper part of your body (T-shirt, coat) ____ 3. Putting on shoes/socks ____ 4. Washing your hair ____ Household activities 5. Making your bed ____ 6. Changing the sheets ____ 7. Washing windows/curtains ____ 8. Dusting ____ 9. Doing the dishes ____ 10. Vaccuum cleaning/sweeping ____ Physical activities 11. Climbing stairs ____ 12. Bending over ____ Leisure activities 13. Walking in the home ____ 14. Going out ____ 15. Speaking/talking ____ General 16. How much does shortness of breath affect your performance of activities of daily living? ( ) Quite a bit ( ) Slightly ( ) Not at all

Score 0) 1) 2) 3) 4) 5)

I do not perform this activity (because I have never needed to or it is irrelevant). I do not experience shortness of breath while performing this activity. I experience mild shortness of breath while performing this activity. I experience severe shortness of breath while performing this activity. Due to shortness of breath, I cannot perform this activity anymore, and I do not have anyone to do it for me. Due to shortness of breath, I cannot perform this activity anymore, and I need someone to help me or to do it for me.

you train this person well. This individual should also have motivational qualities and excellent social skills which would keep your patients together as a cohesive unit when they exercise together. The psychiatrist, dietician and occupational therapist should meet the patients at least once in a 12 week program. (Refer Patient education article in 16th issue of Respimirror on page no.10) There is compelling evidence that pulmonary rehabilitation works for your patient. You will have to persevere and be patient when you start a program. There are enough examples in our own country which shows that if you stick to your guns, there is no reason why you should not be able to run an effective pulmonary rehabilitation program. >> page 3

|Volume IV, Issue V, September-October 2014|RespiMirror 3

Walking

The forgotten exercise par excellence Dr. Sundeep Salvi, Director, CRF

very little physical activity. Physical activity above this minimal level was associated with even greater additional gains in longevity. For example, walking briskly for at least 150 min per week was associated with gain of 3.4 years, while walking briskly for at least 450 min per week increased life span by 4.5 years (Figure 1). More interestingly, physical activity was associated with greater longevity among persons across all body mass index groups (normal weight, overweight, or obese). The greatest effect was noted among normal weight individuals who vigorously exercised regularly. Figure 1: Years of life gained versus intensity of walking exercise (Moore, Plos Med 2012) B Years of life gained after age 40

Years of life gained

W

alking is one of the simplest and most effective forms of exercise you can do to keep yourself fit and live longer. Yet, it remains one of the most neglected things in life. Evolutionarily, the human body was designed for walking because it gave a distinct advantage to help move from one place to another in search of food and shelter. The energy expenditure of our hunter-gatherer ancestors during physical activity was around 1000-1500 kcal/day, which can be reached with 3-4 hours of moderateto-vigorous physical activity (e.g. brisk or very brisk walking). Technological improvements (agricultural - industrial - digital) over the last 350 generations or so, however, have led to dramatic reductions in our physical activity levels, to such an extent that around one third of adults worldwide live a sedentary lifestyle.

Leisure time physical activity (MET-hr/wk)

Energy expenditure of hunter-gatherer ancestors 1000-1500 kcal/day, equals to 3-4 hours of brisk or very brisk walking.

According to the latest Global Burden of Disease Report (2012), physical inactivity has been identified as one of the top 10 leading causes of death in the world. In USA, physical inactivity is the second leading preventable cause of death, after tobacco smoking. While long-term tobacco smoking has been shown to reduce life expectancy by approximately 10 years, physical inactivity has been shown to reduce survival by up to 7.5 years. In 2012, Moore and colleagues (Plos Medicine 2012; 9(11): e1001335) reported on lifestyle factors that affected longevity in a pooled data of 654,827 individuals between the ages of 21-90 years, collated from 6 prospective cohort studies of the National Cancer Institute Cohort Consortium. Each subject was followed up for around 10 years, during which period more than 82,000 deaths occurred. Individuals above the age of 40 years, who performed very low amounts of physical activity during their daily routine, such as 75 minutes of brisk walking per week, lived longer by around 1.8 years compared with those who performed 4

It has been estimated that, in a country like USA, if all people traded their cars for feet and walked only 30 min every day, they would have collectively burnt 10.5 billion calories, saved 24 billion liters of petrol and reduced CO2 emissions by 64 million tons. Similarly, if everyone in England walked in accordance to the recommended guidelines each year, it could prevent 36,815 people dying prematurely, prevent 294,730 cases of diabetes and save 12,061 people from going to the hospital for emergency treatment of coronary heart disease. You can only imagine the benefit walking would have in a hugely populated country like India. Apart from increasing longevity, walking helps burn calories, improves muscle tone, lowers blood pressure, reduces cholesterol levels, reduces the risk of coronary heart disease and stroke, relieves back ache, increases bone density thereby preventing osteoporosis and reduces arthritic pains. The several other benefits, especially among diseased individuals are listed in Table 1. Walking, particularly with good company and in pleasant surroundings reduces depression and anxiety. Walkers also tend to be good sleepers. It is interesting to note that although diet is important, the effect of walking beats the effect of diet when it comes to preventing disease. Walking is, therefore, called the perfect exercise. It is remarkable that something as

RespiMirror|Volume IV, Issue V, September-October 2014|

simple as putting one foot in front of the other can be so restorative and refreshing. But the medical evidence is compelling. Taking regular brisk walks helps one stay healthy, live longer and boosts one's self esteem and mood. There is also something about the regular roll and rhythm of walking that invigorates the mind and sparks creative connections. It is not surprising that many writers use walking to stimulate creativity. Did you know that the exercise of regular walking prevents cancer? In a large, prospective US-based study among 293,511 men and women who were followed over a period of 12 years, people who performed moderate-to-vigorous intensity leisure time physical activity were found to have an 11% overall reduced risk of cancer mortality. When analyzed by cancer site-specific deaths, those who exercised regularly had a 30% lower risk of death from colon cancer, 29% lower risk of death from liver cancer, 16% reduced risk for lung cancer mortality and 20% reduced risk for Non-Hodgkin's lymphoma mortality (Arem, Int J Cancer 2014; 135: 423). Earlier studies reported that regular walking prevented breast cancer by 20-80%, colon cancer by 40-50%, endometrial cancer by 20-40%, lung cancer by 20%-50% (irrespective of whether they smoked or not) and prostate cancer by 30%. It has been estimated that if all people walked regularly in the UK (population of 64 million), it would prevent 10,000 cases of breast and bowel cancer every year. The most consistent observation was seen with breast cancer. A study by the American Cancer Society in 70,000 post-menopausal women showed that regular walking reduced the risk of breast cancer, irrespective of whether they lost weight or not. Those women who walked as well as performed vigorous activity had an even greater reduced risk of developing breast cancer. It has been suggested that regular walking regulates hormones such as estrogen and insulin, both of which are known to boost breast cancer growth.

Walking and Lung Disease:

A recent, randomized study in 29 patients of COPD who had a mean FEV1 of 62%, showed that walking for 40 min along a corridor or a street, climbing stairs for 15 min and exercising the arms with a 1Kg oil can everyday for 5 days in a week for a total of 24 sessions, increased the 6 minute walk distance by 65 meters, increased endurance time and significantly improved quality of life (Pradella, Respir Care 2014). More recently, Mendoza et al (Eur Respir J 2014), studied the impact of a pedometer-based program in 102 patients with COPD having a mean FEV1 of 66%. The pedometer group showed not only significant improvements in the 6 minute walk distance, but also had significant improvements in quality of life. A simple physical activity enhancement program using pedometers can therefore effectively improve physical activity level and quality of life in COPD patients. All patients of COPD must, >> page 5

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Walking importance in pulmonary rehab

therefore, be encouraged to walk, even if the walk distance or time is small. A recent, randomized controlled trial in 32 patients with Idiopathic Pulmonary Fibrosis, who underwent a 12-week, twice weekly, 60-minute exercise training, that included walking, showed significant improvements in the 6-minute walk distance (81 m), oxygen extraction (2.6 mL/Kg/min) and FVC (6%). Walking also improved anerobic threshold (3.1 ml/Kg/min), improved dyspnea scores and improved quality of life (Vainshelboim, Respiration 2014; 378). Similarly, a more recent 10-week study of supervised treadmill exercise walking at 70-80% of heart rate reserve, 30-

45 minutes/session, 3-times per week in patients with interstitial lung disease showed significant improvements in cardio-respiratory function, which was mediated primarily by

Everywhere is within walking distance if you have the time. - Steven Wright

increases in peripheral extraction of oxygen, rather than changes in oxygen delivery (Keyser, J Cardiopulm Rehab Prev 2014). These studies suggest that exercise training should be considered as part of standard care for IPF. A progressive walking exercise program in patients who underwent a lung resection has been shown to improve physical activity, reduce the time required for chest tube removal, reduce hospital stay, improve dyspnea and increase the 6-minute walk distance (Kim, J Korean Acad Nurs 2014; 44: 381). Another study showed that walking was also associated with significant improvements in FEV1 and FVC, 3-6 month post-lobectomy >> page 6

Table 1: Benefits of Walking Disease Conditions

Suggested Walking Program

Potential Benefits

References

Cardiovascular Heart failure

Nordic Walking 5 times/wk x 8 weeks

↑ oxygen extraction ↑ six minute walk distance by 52 m Improves Quality of Life

Piotrowicz, Eur J Prevent Cardiol 2014; Ahead of print

Ischemic heart disease mortality

Walking >1.5 miles/day versus >

surgery for lung cancer (Chang, J Clin Nurs 2014). Quality of life has been shown to be better in patients of lung cancer who walked for between 217 to 282 minutes/week (Lin, Cancer Nurs 2014), while a meta-analysis of 72 randomized controlled studies has shown that walking reduces depression, improves sleep and quality of life in patients with cancer by reducing fatigue (Tomlinson, Am J Phys Med Rehabil 2014; 93: 675).

How much should one walk?

The Centre for Disease Control recommends that adults should engage in moderate-intensity physical activity for at least 30 minutes on 5 or more days a week, or engage in vigorous-intensity physical activity for at least 20 minutes on 3 or more days a week. Details of intensity levels of physical activity can be found here (www.cdc.gov/ nccdphp/dnpa/physical/pdf/PA_Intensity_ table_2_1.pdf). In simple words, moderate exertion means that the heart rate increases and breathing is heavier - the exerciser can still talk, but is unable to sing. Others recommend that individuals take at least 10,000 steps every day for exercise. This can be easily measured with a pedometer.

The easiest way to walk more and stay motivated is to make walking a habit. Avoid distractions such as talking with friends, using a cell phone, listening to music, and watching TV on a treadmill.

Investment walking:

in

Walking requires neither expensive equipment nor a health club membership. Good walking shoes are the only piece of equipment required for walking. They should be comfortable and not cause blisters while walking. Do not buy shoes designated for runners because these 'forward balance' shoes slightly exaggerate a forward bent body position, which is good for running but not walking. Dedicated time and motivation are the other investments required for walking.

What can you do as a physician?

You must walk regularly yourself and set an example for others. Promote walking in

How to walk?

Walking needs to be faster than a stroll. Begin slowly and gradually increase the pace. Ensure that the 30-60 minutes of walking is continuous, as breaks will limit some of the benefits. While walking keep the elbows bent and hands swinging up to eye level if you are able. This will ensure comprehensive physical exercise for the upper as well as lower body and will also benefit the hips, spine, shoulders and abdomen. The head should remain level with the eyes and the focus should be on the surroundings and not gazing downwards.

Diaphragm in COPD : To facilitate or not

Dr. Shakeel Ahmed, PT, University of Florida

and endurance of the inspiratory muscles. We now have concrete evidence supporting the incorporation of an inspiratory muscle training (IMT) component in any pulmonary rehabilitation program. IMT has found to not only positively impact diaphragmatic strength & endurance, but also increase general endurance, reduce fatigue and improve Quality of Life. But the most important outcome of IMT from the patient’s stand point is the reduced perception of dyspnea. Though these benefits occur over a long period of a properly structured strengthening program, the question to whether facilitation of the diaphragm should begin during an exacerbation to prevent atrophy or once the patient is out of exacerbation is still a question which some of us tend to debate on. There is no sufficient evidence to refute any of the two schools of thought, but by understanding the underlying mechanics of the muscle, it

makes more physiological sense to not facilitate the diaphragm while the patient is in exacerbation. We loosely use the term “diaphragmatic breathing” while prescribing exercises to our patients without analyzing the reason to use that exercise. Though we do not have any quantitative, statistically significant data to back my claim, my clinical experience with COPD patients forced me relearn the concept of “diaphragmatic breathing”. We should not prescribe it to patients who present with intercostal retractions, a positive Hoover’s sign or paradoxical breathing.Reducing the airway resistance should be the foremost objective in such cases. It is a fact that in today’s world no scientific claim can be accepted without appropriate evidence, but we should also not let go of the fact that “absence of evidence is not evidence of absence”

P

atients with COPD present with altered respiratory patterns and aberrant recruitment of muscle of respiration. The diaphragm being the muscle of prime importance for its role in inspiration, the impact of hyperinflation on muscle length, angle of pull of the fibers and the morphological changes occurring at the cellular & enzymatic level, contribute significantly to the respiratory impairment of such patients. Patients in an acute exacerbation present a unique challenge to the physiotherapists. During an exacerbation the load on the fatiguing diaphragm is increased and a state of impending respiratory failure results unless optimal pharmacological intervention and or ventilator support is provided at the earliest. One of the primary rehabilitative goals of a physiotherapist is to maintain and over a period of time, increase the strength

6

your community. Advice all your patients to walk regularly. This will motivate more and more people to join. If you have good writing skills, contribute an article or two in local media newspapers, so that more and more people will become aware about the benefits of walking. If you have good leadership qualities, form a morning walkers association in your locality. In England there is an organization called walking for health (http://walkingfor health.org.uk) which is the largest network of health walk schemes that helps people across the country lead a more active lifestyle. This has now caught up in India too. The Max Bupa Health Insurance along with Times Now organized a 2 Km and 5 Km walking event on 9th November 2014 in Mumbai and Delhi. Participating in events like these will go a long way in encouraging this simple, yet extremely beneficial act to help maintain and improve health. According to the words of Paul White, the father of American Cardiology "A vigorous five mile walk will do more good for an unhappy but otherwise healthy adult than all the medicine and psychology in the world".

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Yoga

in pulmonary rehabilitation Dr. Alpa Dalal, MD(Chest), DNB (Respiratory Medicine), Mumbai

Introduction

Comprehensive Pulmonary Rehabilitation (PR) programs are well established to enhance standard medical therapy and reduce disability in patients with chronic lung diseases. The primary goal is to restore the patient to highest possible level of independent function and reduce his or her dependence on family, friends, health professionals and expensive healthcare resources. In COPD patients, development of limb muscle dysfunction is multi factorial. Apart from limitation of physical activity due to dyspnoea, other mechanisms such as inflammation, oxidative stress hypoxemia and nutritional deficiency, anxiety and stress, depression, disturbed sleep and associated comorbidities like hypertension, IHD, Diabetes contribute significantly. A comprehensive PR programme should address these issues for successful results. The other major focus is on reducing dynamic hyperinflation by slowing down respiratory rate. Through there is enough evidence to show that PR programme improves the exercise tolerance, in real life scenario less than 50% of patients show improvement in their daily activity after PR programme because their attitude and behaviour does not change. So there is a need for strategies and intervention for behaviour modification for these patients. In our country lack of availability of good PR centres and home based PR programme and many other logistic issues like travelling to PR centres, severity of disease and disability, limits wider application of these much needed intervention reaching larger patient population. Less than 2% of the diagnosed COPD are able to use PR in our country today.

Is there any intervention which can fill in these gaps?

Yoga is an ancient science and discipline which originated in India. It is designed to bring balance and harmony to physical, mental, emotional and spiritual dimensions. It is a comprehensive science which encompasses various aspects of health, muscle strength, flexibility, with Asanas (postures), improved breathing capacity and gas exchange with Pranayams, reduction in stress and anxiety through breath control and meditation. The word yoga has originated from a sanskrit word “Yuj” which means to unite, to integrate. Yoga is an integration of body, breath, mind, emotions and the intellect. This integration treats the person as a single unit having multiple dimensions. Yogic philosophy

believes that health is not merely an absence of disease but it is a state of complete well being in 7 dimensions of life that is physical, mental, emotional, social, financial, spiritual, and finally time dimension.

Science of Yoga History & Evidence

Yoga is popularly understood to be a program of physical exercises (asana) and breathing exercises (pranayama). But yogic philosophy is a way of life and its purpose is knowledge of the true “self ”. Yogic philosophy originated in India as early as 3000 BC. It is mentioned in Bhagavad Gita. Yoga was systemised and standardised by Rishi Patanjali in the Yoga Sutras (300 – 200 B.C.). Swami Vivekanand introduced yoga to USA in 1893 at the world parliament of religions in Chicago. In 20th century “an almost faddist burst of interest in Hatha Yoga” occurred in the USA. In India two centres Munger School of Yoga in Bihar, founded by Swami Satyanand Saraswati and Swami Vivekanand Yoga Anusandhan Centre at Banglore founded by Dr. Nagarathna AND Dr. Nagendra, started conducting systematic research and publications in yoga giving a true synthesis of science and spirituality. A new stream of medicine, called Mind – Body – Medicine, based on fundamentals of yoga and meditation was pioneered in late 1960s by Harvard professor Herbert Benson, as a possible way to prevent depression, by stress reduction and lifestyle modification. The latest study being carried out at Dr. Benson’s Mind – Body – Medicine institute by Dr. Denninger at Massachusetts general hospital using latest technology in neuroimaging and genomics has allowed scientists to measure physiological and genetic changes in the body after practice of yoga and meditation, in much precise and detailed manner. His study on Kundalini yoga and meditation which was published in PLOS one in May 2014 showed that one session of meditation and relaxation response practice, was enough to enhance the expression of genes involved in energy metabolism and insulin secretion and reduce expression of genes linked to inflammatory response and stress. Nobel Prize winner Elizabeth Blackburn in her study conducted at university of California which was published last year found those 12 minutes of daily yoga and meditation for eight weeks increased telomerase activity by 43% suggesting slowing down of cellular ageing process. This new emerging evidence

and deeper understanding of science of yoga and meditation may persuade more doctors to try this alternative route as a therapeutic and preventive intervention and for holistic rehabilitation of their patients. With this background let us explore together how this scientific knowledge and evidence can be applied to our patients for pulmonary rehabilitation. A systematic review and meta analysis of yoga training in patients with COPD was published in June 2014 total 233 patients from 5 RCTs were included in the analysis. Yoga training significantly improved FEV1 and 6 MWD, but had no significant effect on Po2 and PCo2 levels. Yoga training aids in toning up of peripheral muscles, relaxing chest muscles and improving lung expansion, increasing respiratory stamina, raising energy levels and calming the body and mind. Efficient use of shoulder, thoracic and abdominal muscles can help in effective lung emptying during exhalation reducing dynamic hyperinflation. Though the studies included in metaanalysis varied in terms of patient populations, disease severity, intervention protocol, duration of the intervention and study quality the authors suggested that yoga could be a useful adjunct in pulmonary rehabilitation program for COPD patients.

Components of Yoga (Ashatang Yoga)

Rishi Patanjali’s classical Raj Yoga is divided into eight parts. First four parts are called external limbs and next four parts are called internal limbs. All limbs are interconnected and each limb is a stepping stone for the next limb. External Limbs 1. Yama – universal ethics for living a socially responsible life. 2. Niyama – individual ethics for personal growth and evolution 3. Asana – most popular and known aspect of yoga for improvement in muscle tone, flexibility and strength through sets of postures. 4. Pranayam – breath control and breath awareness for mental and emotional control. Internal Limbs 5. Pratyahara – withdrawal of senses from external world and going with in 6. Dharana – focusing on one object. 7. Dhyana – beginning of meditation 8. Samadhi – deeper stages of meditation. We will discuss the anatomical and physiological aspects of breathing techniques, Asana, Pranayam, and Meditation and their applications for pulmonary rehabilitation. 3 most fundamental principle of yogic science are as follows I. Integration a) Integration and balance between sympathetic and parasympathetic nervous system (down regulation of sympathetic system >> page 8

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Figure - 1

and up regulation of parasympathetic system). This leads to balance and co-ordination of various organ systems with each other and with the nervous system. b) Integration of body – breath – mind. c) Integration of right brain and left brain function. II. Awareness development - through the breath, body, mind. III. Mind management and attitudinal corrections to bring about behavioural and lifestyle modification

Breathing techniques

“Breathing is the first thing we do when we are born and last thing we take before death.” Breath is the most fundamental step before starting any yogic practice. A unique feature of the respiratory system is its dual nervous control system. The involuntary control through centers in pons and medulla and the voluntary control through the motor cortex. Through this voluntary control one can change the rate, rhythm and volume of the breath. Breath is closely connected with thoughts and emotions and acts as a bridge between the body and the mind. All of us have seen our COPD patients experiencing anxiety and panic when breathless, precipitating a vicious cycle. It is very difficult to control the mind and the emotions , but the reverse can be done easily i.e. controlling the breath to control the mind. With regular breath control practices this vicious circle is broken. A typical anxious and stressed person takes shallow, rapid, thoracic breaths. The first step of breath correction is to start taking long, deep belly breaths. (Diaphragmatic breathing) Various breathing practices can help in reducing the respiratory rate, increasing the expiratory time, thereby reducing dynamic hyperventilation. They can be combined with chanting of Aum, movements of the neck and various postures to improve lung expansion and prolong exhalation. Following are the various types of breathing exercises: Sectional Breathing: It is divided into three sections namely abdominal, thoracic and clavicular. 8

Abdominal Breathing: Inhale deeply and expand abdomen fully and exhale while chanting ‘A’ and simultaneously relax the abdomen muscles. Thoracic Breathing: Inhale deeply and expand chest fully in vertical axis and exhale while chanting ‘U’ and simultaneously relax the chest muscles. Clavicular Breathing: Inhale deeply while pulling the shoulders up and exhale while chanting ‘M’ and simultaneously relax the shoulder muscles.

Hand Stretch Breathing: In standing position one has to coordinate breathing with hand movements. Move the arms backwards and much as possible while inhaling fully and bring the arms back to forward position while exhaling fully.

Figure - 3

Tiger Breathing: After taking position of Marjarasana, bend ahead inwards flexing spine up (spine convex) while exhaling slowly through the nose. Slowly arch the spine down (spine concave) while inhaling fully also raise the head up as you inhale slowly. Figure - 4

Yogic breathing: It combines all the three breathing patterns i.e. abdominal, thoracic and clavicular. While inhaling bring abd omen, chest and shoulders up and while exhaling relax the respective muscles and chant ‘AUM (OM)’. Chair Breathing: Person is supposed to pull the chair and relax his hand and side of the face on the chair. Due to this position spine gets a convex arch and that ultimately relaxes the chest and respiratory muscles. After this, while moving backward, one can inhale as deeply and slowly as possible and exhale while moving forward. Figure - 2

Patients with chronic respiratory disability can learn and practice these techniques not only in stable state but also during exacerbation or when hospitalized. Even patients with severe disability requiring home oxygen therapy can be taught to practice some of these techniques.

ASANA

Asana means a ‘posture’. Asanas are the most popular and the most misunderstood components of yoga. Asanas are classified in to 3 basic human postures – standing, sitting, or lying down (supine and prone). According to the purpose of asanas they are again classified in to 3 types. a) Asanas for exercise – for toning of various muscles groups and joints e.g. Bhujangasan (cobra pose). Figure - 5

This technique can be use during exacerbation of dyspnoea and prevent panic attacks.

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b) Meditative asanans – steadiness of posture to make the mind still and steady for meditation e.g. Padmasan Figure - 6

c) Asanas for relaxation – for complete relaxation of body and mind e.g. Savasana (Corpse pose). Figure - 7

The main purpose of asanas is not only comfort and steadiness of the body but also steadiness and calmness of the mind. The basic differences of asanas and other forms of exercises. 1. The movements are slow, gentle and graceful. 2. Every pose is followed by a counter-pose. 3. Stretching alternates with relaxation. 4. The session of asanas begins with relaxation, ends with relaxation and is interspersed with relaxation. 5. A judiciously designed set of 15-20 postures move virtually every joint, and stretch every ligament of the body. Figure - 8 Bhujangaasana (cobra pose)

Figure - 9 Setubandhasana

different body parts act to create resistive forces against which muscles have to work. In the final position the person has to focus his mind on the process of breathing, taking slow deep breaths allowing efficient expansion of different parts of the lungs and he should be focused and be aware of his body, breath, and mind. Thus in the ideal position of an asana the body should be steady and comfortable, breath should be rhythmic, slow and deep, mind should be stable and clam and there is integration and awareness of body, breath, mind and the infinite existence. With regular practice the patient gets into the habit of remaining aware of his breathing, his actions, and his thoughts through out the day. This can be one of the most efficient and effective energy conservation training. This is the beauty of the technology of yoga ‘minimum energy input to get maximum output at multiple levels’. Recommending asanas for pulmonary rehabilitation We must give clear instructions to our patients of COPD, which asanas they can practice safely. In corporation of asanas. Set of 5-7 asanas can be incorporated in to pulmonary rehabilitation programme. Asanas which can be safely practiced by COPD and asthma patients of any severity and any age group are mentioned below. • Standing position – Tadasan, Chakrasan • Sitting position – Parvatasan, Yogamudra • Supine position – Pawanmuktasan, setubandhasan • Prone position – Bhujangasan Recommended sequence • Set of 5-7 asanas after initial warm up • Followed by exercise – aerobic and strengthening • Session should end by relaxation in savasan or with meditation.

Pranayam

This is the fourth limb of patanjali’s Ashtanga Yoga. Prana means subtle life force which provides energy to different organs including mind. Ayama signifies the voluntary effort to control and direct prana. At gross level pranayama starts with breath control then it connects to subtler aspect of prana and the subtlest is the mind. The real purpose is mind control through breath control and awareness development to prepare oneself for meditation. What type of pranayams COPD and asthma patients can practice safely? 1. Anuloma – viloma 2. Bharmari Both these prnayams can be practiced by COPD patients of any severity and any age group. Pranayam that evolves rapid breathing e.g. (Bhastrika, Sudarshan Kriya) should be avoided by patients of COPD and hyperractive airways, as it can aggravate dynamic hyperinflation and bronchospasm.

Anuloma – Viloma Pranayam

(Nadi Shuddhi Pranayam) It is called the king of pranayams. It helps to bring balance between sympathetic and parasympathetic systems, relive stress and improve concentration. There are no contraindications except block nostril in acute rhinitis. Patients of chronic respiratory disability of any severity can practice this pranayam. Number of studies in adults and children and my observation with many of my patients suggests significant improvement in allergic rhinitis as well as asthma symptoms and significant reduction in the frequency of exacerbation. Figure - 11

Kapalbhati

This is considered as a pranayam technique, but it is a cleansing technique and not a pranayam. It involves jerky active movements of expiratory muscles for forceful exhalation. It helps to clear secretions from the nasal cavity and throat. In allergic rhinitis patients. regular practice of kapalbhati reduces nasal blockage and reduces frequency of exacerbations. It helps to strengthen abdominal muscles. But should not be practiced for more than 50 to 100 strokes. It should be avoided in acute exacerbation of rhinitis or asthma, and by Figure - 10 Kapalbhati

In these figures you can see stretching of major peripheral muscle groups and joints (of upper limbs and lower limbs), stretching of the rib cage and intercostals, abdominal muscles and other accessory muscles of respiration along with stretching of the spine. Here the weights of

patients of severe airway obstruction and bullous lung disease.

This pranayam involves alternate nostril breathing. The right hand is held in nasika mudra, it is used to close the nostrils alternately. One round involves 2 inhalation and 2 exhalations. It starts with inhalation from left nostril, then closing the left nostril and exhaling through right nostril, then inhaling through the right nostril and exhaling through left nostril to complete one round. It should be done at an even pace, breathing slowly without making any sound. Keeping so many things in mind along with flawless >> page 10

|Volume IV, Issue V, September-October 2014|RespiMirror 9

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Bring Your Attention, Relax Your Mind

alteration of nostrils needs concentration. It is no wonder then that the practice improves awareness, concentration and breath control allowing more time for effective emptying of lungs during exhalation.

Meditation session at Jupiter Hospital

Brahmari Pranayam

During Brahmari Pranayam the person breaths in through nose and breaths out through the mouth. While breathing out the person also chants ‘nnn…..’ loudly. The chant produced a soothing resonance in the head. The experience of resonance can be enhanced with closing the ears. Regular practice of this pranayam helps in increasing exhalation time, breath hold , reduce anxiety, insomnia and depression. There is no contraindication for bhramari. Figure - 12

Meditation

Last 4 limbs, also called the internal limbs of Rishi Patanjali’s ashtangyoga, are discussed under meditation. How does meditation work? Scientists are now getting close to proving what yogis have held true for centuries- Yoga and meditation can ward of stress and disease. John Denninger, a psychiatrist at Harvard medical school has used latest technology of neuroimaging and genomics to study how the ancient practices of meditation can affect genes and brain activity in chronically stressed. He says ' The kinds of things that happens when you meditate do have effects throughout the body not just the brain.' Large proportions of our patients with chronic respiratory disability are depressed & are constantly living with fear of disability, dependence and death. Meditation would be an excellent therapeutic intervention for them. What is meditation? Meditation means remaining in the present moment, free from thoughts. Our mind always remains in the past or the future, replaying the past negative experiences or creating imaginary fears for the future. Meditation helps to break this habit of the mind and retrain it to remain in the present moment. When and how to meditate? Meditation can be done in any comfortable sitting posture, keeping the spine erect, legs crossed or folded, hands to be clasped and eyes closed. This helps to reduce sensory inputs from outside and harness the energy within. Instead of thinking too much about how to start and when to start, simply observe your breath and you have began your journey into meditation. 10

•

Sit down in a comfortable position on the floor or on a chair, placing one hand on your belly and one hand on your rib cage. 1. Close your eyes as you take deep breaths and focus on the movements of your body as you breathe in and out. 2. Feel the lift of your belly and the expansion of your ribs on your inhalations. 3. Notice the slight compression of your ribs and the drop of your belly as you exhale. 4. Release your arms and focus your mind on your breath for 5-10minutes inhaling and exhaling fully. Meditation for healing of mind and body Our experience with Kriya Yoga and meditation. We are conducting Kriya Yoga and Meditation sessions at Jupiter hospital, Thane, 3 days in a week, for past two years for inpatients and out patients. The holistic science of Kriya Yoga has been described by Paramhansa Yogenada in his famous book ‘Autobiography of a Yogi’. Kriya Yoga was given to mankind by Ancient Himalayan yogi Shree Mahaavatar Babaji and this knowledge was developed into a practical methodology for the common man by Shree Prem Nirmalji, who inspired us and gave his personal guidance to start Kriya Yoga sessions in the hospital. Kriya Kundalini yoga is system of yoga which begins with breath awareness followed by series of co-ordinated rhythmic breaths to elevate the energy from base of the spine to the crown, followed by meditations. Patients are guided into six steps of meditation 1. Conscious awareness of breathing process (mind becomes calm and focussed). 2. Awareness of body sensations (mind becomes sensitive to body sensations) 3. Awareness of thoughts (detached witnessing of thoughts without reacting) 4. Awareness of inhalation-pause-exhalation pause (continuous awareness of breath) 5. Awareness of gap between the thoughts (experience of a state without thoughts) 6. Expanding the awareness to merge with the cosmic energy field (experience of bliss).

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A small study done by us on 10 patients (taking their subjective feedback), before 1st meditation session and after attending 10 sessions, showed significant positive impact on energy levels, fatigue and breathlessness, feeling of anxiety and depression and perception of pain. Over past 2 years many patients with chronic respiratory disability like COPD, Interstitial lung disease, Post TB fibrosis, Post pneumonectomy, chronic persistent asthma, metastatic lung carcinoma and non infectious pulmonary TB, CNS TB, Spine TB have been helped by these sessions. Recommendation for incorporating yoga in PR programme # Asanas, Pranayam and Meditation can be incorporated in the sessions conducted at Pulmonary Rehabilitation Centre in following sequence • Breathing practices & warm up exercises • 5 to 6 asanas after initial warm up • Aerobic and strengthening exercises • Pranayam for 5 to 10 minutes • Session should end with meditation for 10 to 15 minutes. # On the remaining days of the week 30 to 40 minutes of yoga & meditation session to be practiced at home # Yoga is not just a physical or breathing exercise but multi dimensional, comprehensive and a practical methodology which allows us to offer an appropriate intervention to a wide spectrum of our patients. From a mild asthmatic, to a patient of severe COPD suffering with a life threatening exacerbation, Yoga can offer various components of patient care like prevention, rehabilitation, smoking cessation, mind body intervention for anxiety and depression, managing exacerbation and end of life decisions. Subjective Assessment after 10 Kriya Yoga Sessions at Jupiter Hospital

I hope this article helps doctors and paramedical workers to be more informed and confident to prescribe yoga to their patients and show them a ray of hope and happiness.

T

Oxygen Therapy in COPD

he atmosphere is a layer of gases surrounding the earth which protects it from heat and radiation from the sun. This layer of gases, also known as air, is what we breathe. Air comprises of 78.09% Nitrogen, 20.95% Oxygen, 0.93% Argon, 0.039% Carbon dioxide, some other gases and around 1% water vapor. The 21% oxygen present in the air is what fuels most of the cells in our body to produce the energy required for survival and function. This article talks about the various methods that can be used to provide external oxygen therapy to patients with COPD, and other lung diseases. In a normal healthy adult, the lungs extract 420 L of oxygen everyday, which are required for the proper functioning of the body. When the lungs are damaged due to diseases such as COPD, ILD etc., it cannot extract sufficient amounts of oxygen, thereby causing tissue hypoxia (low oxygen levels in tissues) and hypoxemia (low oxygen levels in the blood). Increasing the concentration of oxygen in the inhaled air can help improve tissue oxygenation, relieve hypoxemia, and reduce cardiopulmonary workload. Uses of oxygen for acute conditions such as acute respiratory failure and cardiac arrest are well known, but beyond the four walls of the hospital many patients can definitely benefit from oxygen therapy at home, often referred to as long-term oxygen therapy. COPD is the most common indication for home or long-term oxygen therapy. Table 1 enlists the indications for oxygen therapy in patients with COPD. Research has shown that long-term oxygen therapy helps improve the daily activities of living and extends the life of COPD patients with severe hypoxemia. It is seen that some patients with COPD become transiently hypoxemic during physical activity or exercise, and they require only short-term oxygen. It improves their breathlessness and exercise capacity. Oxygen therapy also increases confidence, as it makes them more independent and also improves their neuropsychological function. Research has also shown that the quality of sleep of patients with COPD improves with oxygen. In addition, it lessens the intensity of right heart failure (Cor Pulmonale). Apart from smoking cessation, oxygen therapy is the only intervention that has been shown to improve survival in patients with COPD and hypoxemia. However, we must remember that when supplemental oxygen is discontinued for patients with COPD, hypoxemia reappears. Therefore, oxygen should be given for at least 15 hours a day. The key for optimal therapy is titrating oxygen correctly to avoid hypoxia. It is also important to be cautious during special activities such as air travel. At sea level, we breathe in oxygen rich air. As the altitude starts increasing the air becomes thinner

Ms. Madhuragauri Shevade, CRF

Table 1: Indications for Oxygen therapy in COPD Continuous oxygen use (>15hrs/day)

Intermittent oxygen use (As needed)

Resting PaO2 ≤ 55 mm Hg

Desaturation (SpO2 ≤ 88%) with activity

Resting PaO2 of 56-59 mm Hg with any one of the following: • Right heart failure Desaturation • Pulmonary (SpO2 ≤ 88%) at night Hypertension • Polycythemia

During air travel (Requires specific titrated flow) (SpO2= oxygen saturation by pulse oximetry. PaO2= Partial pressure of oxygen)

and the oxygen become scarce. This causes worsening of hypoxia in patients with COPD. Hence titrating the oxygen levels to correct this hypoxia is required during air travel. Although correcting hypoxia is the first priority, precautions such as providing the correct flow of oxygen by monitoring the oxygen levels in the blood must also be taken to avoid the harmful effects of hyperoxia. It Table 2: Potential Threats of Hyperoxia and oxygen therapy • • • • • • •

Worsened V/Q mismatch Depression of ventilation Absorption atelectasis Reduced cardiac output Damage from oxygen free radicals Increased systemic vascular resistance Delay in recognition of clinical deterioration

is important to remember that hypoxia is the only drive that ensures adequate ventilation in patients with moderate-to-severe COPD. If these patients are given high flows of oxygen, they start hypoventilating, which worsens the blood gases. High flows of oxygen may therefore kill COPD patients. Therefore it is crucial not to provide high levels of oxygen to COPD patients. Table 2 enlists the potential threats of hyperoxia. When prescribing oxygen therapy, various modalities can be used. Generally the respiratory therapist and the vendor can help the patient choose the correct delivery method, depending on their activity level, everyday routine, and budget. With all the systems, oxygen delivery devices such as the nasal prongs/cannula, oxygen masks are used. Devices such as the venturi mask which provides fixed fraction of inspired oxygen or FiO2 can also be used.

Table 3: Oxygen delivery devices Name of equipment

Flow

Nasal Canula

Disadvantages

0.25 – 8 L/min

Can be used in adults, children and infants. Easy to use Disposable Low cost Well tolerated

Unstable, can cause nasal dryness, bleeding, polyps, deviated septum, higher flows uncomfortable

5-10 L/min

Can be used in adults, children and infants Easy to apply Disposable Inexpensive

Uncomfortable Must be removed for eating

Simple Mask

Venturi Mask

Advantages

Easy to apply Variable according to Disposable specific oxygen percentage. Inexpensive (21%-60%) Stable, precise FiO2

Limited to adult use Uncomfortable Noisy Must be removed for eating

Table 4: Venturi masks and FiO2 ranges Color of Venturi Valve

FiO2

Blue

21%

White

28%

Orange

31%

Yellow

35%

Red

40%

Green

60% >> page 12 |Volume IV, Issue V, September-October 2014|RespiMirror 11

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Following are the various systems that one can choose from

Home oxygen concentrator

An oxygen concentrator is a device that physically separates oxygen present in room air from nitrogen, carbon dioxide and water. Compressed air passes through molecular sieves which are present inside the concentrator. These sieves contain sodium aluminum silicate pellets, also called Zeolite, that absorbs nitrogen, carbon dioxide and water vapor, and the oxygen that remains is stored for use in an accumulator. At flows of 1-2L/m the concentrator delivers 92%-95% oxygen. At flows of 3-5L/m the oxygen percent falls to 85%-93%

90-95% Oxygen Molecular Sieve containing Zeolite

Room air containing (N2, O2, CO2, Ar, H2O)

Interesting facts about Zeolite • In airplanes, oxygen generating systems also use Zeolite in conjunction with pressure swing absorption to remove nitrogen from compressed air and supply oxygen at high altitudes. • Zeolite stones are also used in aquariums where they absorb ammonia and other nitrogenous compounds.

Nitrogen, CO2, Water Vapor

Advantages: • The oxygen gas produced is not wasted • Most effective method for oxygen generation when continuous use is required • Eliminates need for regular oxygen cylinder replacement Disadvantages: • It requires electricity at all times • In case of power loss, backup oxygen supply like the cylinder is required • Cannot be used along with mechanical ventilators • Oxygen concentration reduces with increasing flows • Costs: Approx. `40,000-90,000

Zeolite Pellets

Portable Oxygen Concentrator

A portable oxygen concentrator is similar to home oxygen concentrators, but they’re smaller and easy to carry.

Liquid Oxygen

Liquid oxygen stored under a pressure of 20-25 psig at a temperature of approximately -300°F or 184.4 °C 1 L liquid oxygen provides 860 L of gaseous oxygen. For a typical flow of 2L/min, 1L liquid O2 will last for 8-10 hrs.

Compressed Oxygen Cylinder

Compressed cylinder contains oxygen in gaseous form. It requires a pressure reducing valve and a flow-meter to deliver the desired flow of oxygen

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Advantages: • Lightweight (2-4 kg) • Can be operated on electricity as well as battery • Can be plugged into a car lighter electrical outlet Disadvantages: • Expensive • Cannot be used along with mechanical ventilators • Cost: Approx `1,00,000-3,00,000 Advantages: • Lightweight, portable • Can deliver oxygen at all flow rates (1-15 L/min) • Does not require electricity • Relatively silent • More amount of oxygen can be stored in liquid form Disadvantages: • Expensive (approx. `600-800/L) • Contents of reservoir and cylinder evaporates • Patients need to follow safety instructions when filling the portable unit. • Cannot be used along with mechanical ventilators Advantages: • No waste or loss of gas • Small cylinders are portable • Available easily • Can deliver wide range of flows (1–15 L/min) Disadvantages: • Large cylinders are heavy, bulky and not portable • High pressure safety hazard (approx. pressure of 2200psi) • Regular supply needed from vendor depending on use • Cost: Smallest cylinder to largest cylinder Approx. `6500-12500 for sale Approx. `550-650 per month for rent >> page 13

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Table 5: Compressed Oxygen Cylinder specifications by size C

D

JD

E

G

H

New Name

Old name M2

M4

A ML6

M6

B M7

M9

M15

M22

M24

M60

M/MM/M122

M250

Diameter(inches)

2.5

3.2

4.3

3.2

4.3

4.3

4.3

5.3

4.3

7.3

8

9

Height (inches)

5.3

8.5

7.6

11.5

9.1

11

16.5

16.5

25.5

23

36

52

Empty Weight (Kg)

0.3

0.7

1.2

0.9

1.4

1.6

2.4

3.6

3.5

10.1

17.9

51.7

Capacity (L) at 2,200 psi

42

113

165

164

198

255

425

640

680

1738

3455

7080

This information is intended to be used as a guide only. Dimensions and names may vary by manufacturer

When using compressed gas cylinder, it is necessary to estimate how long the contents will last. This can be calculated using the flow of gas, the size of the cylinder and the cylinder pressure at the beginning of therapy. With the help of cylinder factor according to the size of cylinder (table 6) and following equation, the duration of flow can be estimated.

Duration of flow (min) =

Cylinder Pressure (psig) X Cylinder factor Flow (L/min)

Table 6: Cylinder Factors for calculating duration of flow (mins) Gas Oxygen/Air

D/M-15 0.16

For example: You need to determine how long an H or M250 size oxygen cylinder with a pressure of 2000 psi will last for a COPD patient who requires a flow of 2 L/min. The cylinder factor for the cylinder is 3.14 (table 6). If we apply the value in the equation

E/M-24 0.28

Cylinder Size G/M/MM/M122 2.41

Duration of flow (min) = =

H and K/M250 3.14

Cylinder Pressure (psig) X Cylinder factor Flow (L/min) 2000 X 3.14 2

= 3140 mins or approx. 52 hrs The cylinder will last for approximately 52 hours

Mr. Nitin Vanjare, CRF

Lungfish

Fig. 2 : Dissected lung fish Fig. 1 : Lung fish

W

e all know that a fish is an aquatic animal and it cannot survive out of water. A fish breathes by taking water in its mouth and forcing it out via the gill passages. As water passes over the thin walls of the gills, dissolved oxygen present in the water diffuses into the blood and thereby enters the circulation. Surprisingly, there are few fishes that, in addition to gill breathing, have lungs. These fishes are therefore rightly named as Lungfish. Their lungs have large number of honeycomb-like cavities supplied with

fine blood vessels where gas exchange takes place. There are three types of lungfish which are found in Australia, Africa and Southern America. The African lungfish is a perfect example of evolutionary adaptation. As any other common fish, the African lungfish breathes through its gills when in water. When the water level goes down in summer, other fishes die due to lack of oxygen but the lung fishes switch their breathing mode from the gills to the lungs. They manage to survive in small water holes breathing the atmospheric air. As the summer becomes worse, these lung fishes burry themselves underground by eating mud and pushing it out of the gills.

After burrying, they form a cocoon around themselves with the help of certain mucus like skin secretions. This cocoon has a small opening for breathing. They further undergo estivation during which their metabolism slows down by 1/60th of the original rate, they rely on their muscles and body fat (autophagy) for source of food and water. Studies have shown that the extracts from the brains of these fishes injected into rats, caused them to become lethargic, in addition, the body temperature of the rats had fallen down by 5 degree Celsius and the metabolic rate by 33 percent, further the rats also lost appetite.

|Volume IV, Issue V, September-October 2014|RespiMirror 13

Pulmonary Rehabilitation in Interstitial Lung Disease

I

nterstitial Lung Disease (ILD) is a diverse group of over 150 disorders characterized by varying degrees of fibrosis and inflammation of the lung parenchyma or interstitium. These disorders share restrictive ventilatory physiology along with interstitial thickening with varied inflammation. Usually the interstitial damage is irreversible and some patients demonstrate a slow, gradual progression over many years while others can remain stable for many years. Few patients experience a sudden decline with an episode of acute respiratory worsening, after ending in death. If they survive this episode they experience markedly reduced lung function and exercise capacity.

Problems faced by ILD patients

Severe exertional dyspnea, cough and exercise intolerance are characteristic and disabling features of ILD patients. • Exercise intolerance in ILD patients results from several processes, including altered lung mechanics with low lung compliance, alterations in respiratory drive and gas exchange disturbances (impaired diffusion, increased dead space & ventilation – perfusion mismatch). • As lung compliance is reduced, more negative pressure is required to inflate the lung with each breath thus respiratory muscles have to work harder thereby increasing work of breathing. Also a greater fraction of total body metabolic energy is diverted to respiratory muscles to sustain a given level of ventilation thereby leaving a smaller fraction available for working limb muscles during exercise. This leads to greater lactic acid production from limb muscles further stimulating ventilation and increasing work of breathing, which also results in early onset of fatigue. • Normally DLCO increases by 40 to 100 % with increasing cardiac output from rest to exercise, mainly due to the result of opening or distention of pulmonary capillaries that increases the surface area for gaseous exchange. The ability to increase DLCO is important in maintaining oxygen saturation while exercising. • Patients with moderate-severe ILD are unable to augment DLCO during exercising, and therefore present with Exercise induced hypoxemia. 14

Research & Pulmonary Physiotherapist, P. D. Hinduja National Hospital & MRC

The vicious The viciouscycle cycle Chronic Pulmonary Disease Decreased Breathlessness

Increased Breathlessness Physical Deconditioning

Physical Reconditioning

Immobility

Pulmonary Rehabilitation

Decreased Exercise Capacity

Current picture of ILD

At present the pharmacotherapeutic modalities available are ineffective in stopping the natural course of ILD, have many side effects and largely produce only as palliative benefits. Lung transplantation is the only modality which improves survival.

Dr. Mrinmayee Koltharkar,

Increased Exercise Capacity Difficulty to do dayto-day activities

• Chronic use of glucocorticoids aimed at of reducing inflammation, retarding disease progression and protecting of lung function, can lead to multiple complications including obesity, skin changes, systemic hypertension, hyperglycemia, loss of bone density and muscular atrophy, which further aggravate the exercise intolerance. • Prolonged use of Immunosuppressants such as methotrexate may further worsen pulmonary fibrosis and predispose for developing lung infections by suppressing leukocyte count

Effect of Pulmonary Rehabilitation on ILD

ATS/ERS suggest that patients with ILD should be encouraged to enroll in Pulmonary Rehabilitation (PR) program. PR programs involve aerobic conditioning, strength and flexibility training, educational lectures, nutritional interventions, and psychosocial support. Mrs Menon, ILD patient says, ‘Prior to PR, I was barely able to talk for 5 minutes. Coughing bouts used to disturb me. 3 months

Ability to do dayto-day activities

after Pulmonary Rehabilitation I’m now able to talk for 15 minutes and walk for 20 minutes continuously without any discomfort. Energy conservation techniques have helped me cope with daily activities. PR has improved my Quality of Life!’

Exercise prescription in ILD

Once diagnosed and managed medically well by Chest Physicians or General Practioners, evaluation and recommendation from Physiotherapist, Occupational Therapist and Nutrition Therapist are very helpful in formulating individualized PR program. CPET is desirable, when feasible to assess the basis of patients exercise limitation and to guide formulation of PR exercise prescription. A 6MWT can also be used as an effective measure for baseline exercise tolerance, assisting in formulating exercise prescription and assessing gains in exercise tolerance after PR in ILD patients. Chang and colleagues showed that amongst several QOL questionnaires SF-36 & SGRQ best correlate with the degree of physical impairments in ILD patients. The Borgs Dyspnea Scale, Baseline Dyspnea Index,

Effects of exercise training in ILD Chest Physician's View • • • • •

Improve exercise endurance Improve VO2 Max (Maximal oxygen consumption) Improve ventilation – perfusion matching Improve cardiovascular conditioning Increase DLCO secondary to increased cardiac output • Improve oxygen extraction, endurance & efficiency of skeletal muscles • Reduce lactic acidosis and minimize stimulation of ventilation during exercise • Desensitization to the perception of dyspnea

RespiMirror|Volume IV, Issue V, September-October 2014|

Patient's View • Decreasing Breathlessness • Improving Exercise capacity • Psychosocial benefit • Decrease hospitalizations • ReducedLengthofHospitalstayevenif hospitalized • Reduced number of exacerbations/ infections • Improving Quality of Life

>> page 15

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Exercise Prescription in ILD TYPE 1) Aerobic Training

MODE

INTENSITY

Treadmill walking

Initial speed = 80% of the 6MWT speed Dyspnea: 3-4 on Modified Borg’s scale (1-10)

Cycle Ergometry

Initial Intensity = 60% of peak cycle work rate (Wmax) Dyspnea: 3-4 on Modified Borg’s scale (1-10)

2) Strength training

Free Weights/ isokinetic machines

40% - 60% of the 1 RM

3)Breathing Exercises

As tolerated Deep Breathing, Segmental expansion by patient & chest Mobility exercise along with respiratory muscle strengthening

4) Flexibility Exercises

Stretching Tai chi

Maintain each stretch below discomfort level

Medical Research Council and Visual Analog Dyspnea Scale have been used to measure dyspnea in ILD but their responsiveness to change resulting from PR needs to be further validated. Educational topics of particular importance to ILD patients should emphasize on, • Symptom management (including training with pursed lips and body positions to reduce dyspnea, discussion of strategies to control cough and performance of chest wall stretching exercises to improve chest wall compliance) • Training with energy conservation, environmental modification and pacing techniques to assist ADL performance • Importance of Oxygen supplementation • Relaxation techniques • Recreational therapies such as yoga or tai chi • Risks versus benefits of Pharmacologic therapies

• • •

PROTOCOL Continuous or interval

DURATION a combination with a total duration of 30 minute (shorter initially)

FREQUENCY 3 times a week

PROGRESSION increasing duration, speed, and eventually slope

increasing the duration and the load

Low resistance high repetitions

With breathing co-ordination 8-10 different major muscle groups

Hold 20-60 second stretch

Vaccinations Importance of proper Nutrition (emphasizing on antioxidant, protein rich diet) and Preparation for as well as recovery from Lung Transplantation. When planning for PR, simple maneuvers should be implemented first, such as efficient breathing techniques and improving ergonomics during ADL’s to enhance metabolic energy conservation. Walking being easiest mode of exercise requiring no special equipment can be done at individuals own pace and readily integrated into other ADL’s should be encouraged initially. In sedentary ILD patients an initial training of 20-30 min /day for 5 d/week for 6-8 weeks is helpful in establishing baseline level of fitness. For patients with severe ILD, thereby having poor exercise endurance, the training sessions can be further divided into several shorter segments with rest periods in between.

2 -3 times a week with at least 1 day rest between sessions

2-3 Sets of 10 Repetitions each and eventually progressed to 80% of 1 RM

Daily

Increasing number of repetitions and holds

3 times a week

Progress as ROM allows

Harris-eze et al showed that Oxygen supplementation improves exercise performance among hypoxemic patients with ILD. A saturation of greater than 88% should be maintained during exercise.

Maintenance therapy - ‘Use It or Lose It’

The positive effect of a training program is lost once the program is discontinued. So a Maintenance program is mandatory in ILD patients with timely follow up & re-assessment.

Further Recommendation

The need of rehabilitation in ILD has only been recently realized. Much of the work on pulmonary rehabilitation work has been done on COPD and data has been applied to other chronic respiratory conditions. While ATS/ERS joint committee in their statement on ILD subgroup have given weak positive recommendation on pulmonary rehabilitation due to lack of strong evidence, more research in this field is desired.

18th GINA 2014 1st Winner

Dr. Deepak Muthreja

2nd Winner

Dr. Ganesh Patil

Final Year Resident, Pulmonary Medicine Dept., P.D.U. Hospital and Medical College, Rajkot -360001.

TB Chest Resident, GMC Kota, Rajasthan.

|Volume IV, Issue V, September-October 2014|RespiMirror 15

1st NATIONAL MEETING OF THE HEADS OF THE DEPARTMENTS OF GENERAL MEDICINE OF GOVERNMENT MEDICAL COLLEGES OF INDIA

O

n the 20th of September 2014, 38 Heads of the Departments of Medicine from across 25 cities, 12 states and 2 union territories gathered together at Chest Research Foundation to debate and discuss three major issues of concern related to respiratory medicine, service, education (both UG and PG) and research. Organized by Chest Research Foundation after the very successful earlier meeting of the Heads of the Departments of Respiratory Medicine last year this was the first time that a group of HODs from across India came together for such a unique purpose. The prime conclusion of the meeting was a unanimous opinion that exposure to respiratory medicine at undergraduate level should be increased. It was unanimously agreed that it was important for a medical graduate in India to be competent and skilled in the management of the common respiratory ailments like Asthma, COPD, Tuberculosis and pneumonias. A strong recommendation made was to incorporate the integrated system of education which is currently being promoted by the Medical Council of India as the colleges who have incorporated it since the past 2 years are noticing a remarkably good acceptance in their students. Training of Medicine post graduate students in the respiratory departments should be increased for at least three months and the

1st National Meet of the Heads of Department of Medicine, 20th September 2014 quality of their training should be improved. Similarly, even the PG students of Respiratory Medicine should be trained more intensively in the General Medicine departments. The departments should upgrade themselves in infrastructure and expertise to meet the demands of improved training. Subtle changes in the examination pattern both in UG and PG exams will definitely help. Inclusion of Spirometry, Peak Flow Meter, inhalation Devices etc in the table vivas will motivate students to learn these diligently. An issue that emerged consistently and independently during the discussions was improvement of communication skills amongst the budding

doctors and inculcation of compassion towards their patients and their families. Reviewing the approach towards research was also identified as a key area which needs to be worked upon. A pivotal role for Chest Research Foundation was identified and CRF will be working closely with medical colleges to help them implement the recommendations. These recommendations and suggestions that were unanimously agreed upon have the potential to improve the respiratory health status of our country by ensuring that the medical colleges create good quality community physicians and doctors who can handle the most common respiratory ailments effectively.

- CRF’s training programmes -

- To read the previous issues of Respimirror visit www.crfindia.com -

Chest Research Foundation Marigold Premises, Survey No 15, Kalyaninagar, Pune 411014, Maharashtra, INDIA. Phone: +91 20 27035361/66208053 Fax: : +91 20 27035371. Website: www.crfindia.com NOTE : FOR PRIVATE CIRCULATION ONLY.

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For your feedback / queries write to [email protected] Do you want to conduct a training programme in your city? Please write to Mrs. Monika Chopda at [email protected]

Edited by : Mrs. Monika Chopda Published by : Chest Research Foundation, Pune n Printed by : Bookmark Publications, Pune

RespiMirror|Volume IV, Issue V, September-October 2014|