141

Pulmonary Rehabilitation
John R. Bach, MD

Synonyms
None

ICD-9 Codes
E0450 Invasive mechanical ventilation
E0461 Noninvasive mechanical ventilation
E0482 Mechanical insufflations-exsufflation

DEFINITION
Pulmonary rehabilitation has been defined as the art of medical practice wherein
an individually tailored, multidisciplinary program is formulated through which
accurate diagnosis, therapy, emotional support, and education stabilize or reverse
both the physiopathology and psychopathology of pulmonary diseases in an
attempt to return the patient to the highest possible functional capacity allowed by
his or her pulmonary handicap and overall life situation. 1-2 Program goals are to
reverse the cycle of dyspnea and deconditioning, to optimize airway secretion
management and respiratory muscle function, to reduce frequency of
hospitalizations and pulmonary complications, to address psychosocial factors to
facilitate rehabilitation and community integration, and to improve daily function.
1-4

Candidates for outpatient pulmonary rehabilitation include pediatric and adult

individuals who can benefit from these goals, who have respiratory muscles or
pulmonary dysfunction that limits their activities or life expectancy, and whose
conditions are sufficiently stable for outpatient management.

Overview of Contrasting Pathologic Processes and Approaches and

Outcomes
In development of a prescription for an outpatient pulmonary rehabilitation
program, it is essential to distinguish between pulmonary dysfunction due to lung
or airways disease or oxygenation impairment and impairment of alveolar
ventilation in the presence of essentially normal lung parenchyma. Patients with
oxygenation impairment are often hypoxic with a normal carbon dioxide level.
Patients with ventilator impairment retain carbon dioxide from muscle
dysfunction, activity overload, or central hypoventilation. With this classification
scheme, a clinician can better generate a focused outpatient pulmonary
rehabilitation prescription. Subsequently, this chapter outlines treatment based on
classification. Conditions associated with oxygenation impairment are listed in
table 141-1. Whereas either one or the other almost always predominates, when

impairments overlap, the prescription must reflect approaches for both

conditions.5
Potential outcomes of outpatient pulmonary rehabilitation include decrease
hospitalization, decreased morbidity and mortality, decreases symptoms,
improved

quality

of

life,

increased

functional

activity,

improved

neuropsycological condition, increase ability to work, effective use of assistive

respiratory technology. Each prescription is individual specific and is adjusted
according to the patients progress.

Incidence
The prevalence of chronic obstructive pulmonary disease (COPD) in the adult
population is approximately 4% to 6% in men and 1% to 3% in women. In the
1996 National Health Interview Survey, approximately 14 million adults had
chronic bronchitis. COPD is the fourth leading cause of death in the United States
and the most common cause of oxygenation impairment. 6,7
Respiratory failure associated with weakness of respiratory muscles (ventilator
impairment) has an incidence of 1 in 800, the approximate incidence of patients
with neuromuscular diseases. However, both acute and chronic respiratory failure
also results from respiratory muscle dysfunction associated with central nervous
system diseases such as cerebrovascular disease and traumatic brain injury.
Almost 50% of home mechanical ventilation users have primarily ventilatory
impairment because their prognosis with ventilator use in much better than that of
ventilator users with primarily oxygenation impairment. Attempts are being made
to objectify the need for and prescription of ventilators for home use.8

Table 141-1 Conditions Associated with Oxygenation Impairment and

Ventilatory Impairment
Condition with predominant oxygenation impairment
Chronic obstructive pulmonary disease
Asthma

Emphysema and emphysema that follows lung volume reduction surgery

Cystic fibrosis
Bronchiectasis
Some restrictive diseases (e.g., pulmonary fibrosis, primary parenchymal disease)
Condition with predominant ventilator impairment
Myopathies
Duschene muscular dystrophy
Becker muscular dystrophy
Limb-girdle muscular dystrophy
Emery-Dreifuss muscular dystrophy
Facioscapulohumeral muscular dystrophy
Congenital, autosomal recessive, myotonic muscular dystrophy
\

Generalized nondystrophic myopathies

Inflammatory Bowel Disease-Associated (Chron Disease and Ulcerative Colitis)

Arthritis Congenital, metabolic, inflammatory myopathies
Myasthenia Gravis
Mixed connective tissue disease myopathies
Neurologic disorders
Amyotrophic lateral sclerosis
Spinal cord dysfunction
Spinal muscular atrophies
Motor neuron diseases
Poliomyelitis
Hereditary sensory motor neuropathies
Phrenic nerve neuropathies, Guillain-Barre syndrome
Multiple sclerosis
Friedreich ataxia

Myelopathies
Botulism
Sleep-disordered breathing
Central and congenital hypoventilation syndromes
Hypoventilation associated with diabetic microangiopathy
Down syndrome
Familial dysautonomia
Musculoskeletal
Thoracic wall deformities
Kyphoscoliosis
Ankylosing spondylitis
Osteogenesis imperfecta
Rigid spine syndrome
Spondyloepiphyseal dysplasia congenital
Restrictive lung diseases
Obesity hypoventilation
Diseases of the pleura and chest wall
Tuberculosis
Milroy disease

SYMPTOMS
Symptoms of oxygenation impairment include dyspnea on exertion or during
routine activities of daily living, anxiety, depression, headaches, and difficulty
with concentration.9 Patient may have chronic sputum production, coughing,
wheezing, chest pains that vary with the respiratory cycle, weight loss, orthopnea,
sleep disturbances, and low endurance. A constellation of allergy symptoms may

also be seen. Associated symptoms may include fever and hemoptysis, as in

patients with bronchiectasis.
Patients with predominant ventilator impairment most commonly complain of
fatigue. Other symptoms can include exertional dyspnea, weight loss, sleep
disturbances, low endurance, morning headaches, and frequent arousals. For
patients who use a wheelchair or scooter, minimal symptoms are common until
anxiety or inability to fall asleep occurs during otherwise benign intercurrent
respiratory tract infections-a harbinger of respiratory failure. 10 Episodes of acute
respiratory failure are common for patients with neuromuscular weakness with an
ineffective cough.

PHYSICAL EXAMINATION
Predominant Oxygenation Impairment
For patients with lung or airways disease, the physical examination depends on
the underlying pathologic process (see Table 141-1). For patients with COPD, the
examination may reveal plentiful sputum production, auxiliary respiratory muscle
use, and barrel chest. Auscultation reveals wheezes, rales, or hyperresonant lung
sounds. Evaluation with pulse oxymetry during rest and exercise will often
demonstrate worsening oxygenation impairment with activity.6

Predominant Ventilatory Impairment

All generalized neuromuscular diseases cause varying degrees of weakness of the
inspiratory (breathing), expiratory (coughing), and bulbar-innervated (speech,
swallowing, and air protection) muscles. Patients may have increased respiratory
rate, shallow breathing, diaphragmatic or paradoxical breathing, accessory
respiratory muscle use, nasal flaring, peribuccal or generalized cyanosis, flushing
or pallor, drooling, difficulty in control of airway secretions, dysphagia, or
nasality of speech.5

FUNCTIONAL LIMITATIONS
Baseline levels of function, including exercise tolerance and ability to perform
activities of daily living, may be greatly diminished. There may be difficulty with
control of airways secretions, difficulty with chewing and swallowing of the food,
and decreased social interaction. Many patients require ventilator use to rest
inspiratory muscles to avoid or to diminish respiratory sumptoms. Activities of
daily life may be diminished by generalized muscle dysfunction or by specific
impairment of respiratory muscles. For example, tachypnea does not allow
patients sufficient time to chew and swallow. This results to malnutrition that
further decreases respiratory function. Management with ventilatory assistance by
a simple mouthpiece diminishes tachypnea and often results in better nutrition and
improved strength (Fig. 141-1).

DIAGNOSTIC STUDIES
Diagnostic testing distinguishes between predominant ventilator impairment and
predominant

oxygenation

impairment.

With

predominant

oxygenation

impairment, patients have at least one of the following: respiratory limitation to

exercise at 75% of predicted maximum oxygen consumption; irreversible airway
obstruction with a forced expiratory volume in 1 second (FEV1) of less than 200
mL or an FEV1 to forced vital capacity ratio (FEV 1/FVC ratio) of less than 60%;
or pulmonary vascular disease with carbon monoxide diffusion capacity of less
than 80% of predicted.
With predominant ventilator impairment, patients have at least one of the
following: hypercapnia, respiratory limitation to exercise at 75% of predicted
maximum oxygen consumption; or diminished vital capacity with normal to high
FEV1/FVC ratio, diminished cough peak flows, decreased maximum inspiratory
and expiratory pressures, and low lung volume measurements (i.e., total lung
capacity, functional residual capacity, and residual volume). Many such patients
have thoracic wall deformity. It is extremely important to measure unassisted as
well as assisted cough flows for these patients because they most often develop

respiratory failure as a result of ineffective coughing.10 Assisted cough flows are

created by air stacking consequtively delivered volumes of air provided through a
manual resuscitator to the maximum volume that can be held with a closed glottis.
At this point, an abdominal thrust is delivered in conjunction with glottis opening.
The expelled air is measured as a cough flow into a peak flow meter.

FIGURE 141-1. A 17-year-old with mild spinal muscular atrophy type 1 who is continuously
ventilator dependent uses a mouthpiece during daytime hours and a nasal interface during sleep.

Tests to Determine Candidates for Rehabilitation for Predominant

Oxygenation Impairment
Active patients who are still be able to walk several blocks but who have noted
yearly decreases in exercise tolerance or who have recently begun to require
ongoing medical attention for pulmonary symptoms or complications are ideal
candidates for outpatient pulmonary rehabilitation.
Clinical exercise testing can be determine the extent of the patients functional
impairment due to pulmonary disease. It can diagnose and measure functional
reserve and the capacity to perform exercise, the factors that limit exercise, and
the reasons for exercise-related symptoms.11-13 Clinical exercise testing permits the
clinician to determine whether the primary disability is pulmonary, cardiac, or

exercise-induced bronchospasm.13 The last two diagnoses and even purely

restrictive pulmonary syndromes are commonly mistaken for COPD. When it is
performed both before and after the rehabilitation program, clinical exercise
testing documents the patients progress.
Vital signs, electrocardiography, oxygen consumption, carbon dioxide production,
respiratory quotient, ventilatory equivalent, minute ventilation, and metabolic rate
are monitored during clinical exercise testing, which is done with use of treadmill,
stationary bicycle, or upper extremity ergometry. All patients undergo a 3-, 6-, or
12-minute walk test. The patient is instructed to gradually increase speed and
duration on subsequent walking exercise tests.11-15 A clinical exercise test advances
until oxygen consumption fails to increase; maximum allowable heart rate for age
is reached; or electrocardiographic changes, chest pain, severe dyspnea, or fatigue
occurs. Oxymetry is performed to determine the need for supplemental oxygen
therapy during reconditioning exercise (pulse oxyhemoglobin saturation [SpO 2]
SpO2 < 90% to 95%) or on a long-term basis (PO2 < 60 mm Hg). When metabolic
energy cost studies are not available, maximum exercise tolerance may be
estimated from pulmonary function data. 11-13, 16

Predominant Ventilatory Impairment

Patients with primarily ventilator impairment undergo spirometry to measure vital
capacity in sitting and supine positions and maximum insufflations capacity ,
unassisted and assisted cough peak flows by peak flow meter, end-tidal carbon
dioxide measurements, and pulse oximetry.17 Sitting minus supine vital capacity
greater than 20% provides a strong indication of diaphragm weakness out of
proportion to accessory inspiratory muscle dysfunction . When the vital capacity
is less than 80% of normal, the patient is trained to perform maximal insufflation
techniques, such as air stacking as noted before. Air stacking along with manually
and mechanically assisted coughing is aimed at maintaining adequate airway
secretion clearance and preventing atelectasis and pneumonia. Cough peak flows
of less than 270 L/min indicate initiation of the oximetry-respiratory aid protocol

10

to be described later. Symptoms of nocturnal hypoventilation, end-tidal carbon

dioxide above 45 mm Hg, or daytime or nocturnal oxygen desaturation below
95% warrant a nocturnal trial of noninvasive intermitten positive pressure
ventilation.17

Differential Diagnosis
Decondioting
Cardiac dysfunction
Pulmonary infection
Obesity

TREATMENT
Initial
Predominant Oxygenation Impairment
The main treatment for pulmonary rehabilitation is summarized in Table 141-2.
The patient and caregivers are educated in preventive care measures. Smoking

TABLE 141-2 Pulmonary Rehabilitation

Basic outpatient pulmonary rehabilitation program
Airway
secretionofelimination
techniques and devices
Intial
assesment
:
SmokingRespiratory
cessation program
disease process
Underlying medical disorder
Exercise program :
General medical disorder
Functional status
Ventilatory
muscle training
Patients
goals
Endurance and strength training
Select treatment goals
Breathing retraining
Interdisciplinary team management
Alternative breathing techniques
Medication optimization
Energy conservation technique
Adjustment of supplemental oxygen therapy
The terapeutic modalities
Adaptive devices mobility equipment
Psychosocial conseling
Patient and caregive education
Maintenance program

11

cessation is emphasized to reduce chronic phlegm production and to decrease the

rate of annual loss of FEV1, to the level of nonsmokers.18,19 Avoidance of
atmospheric or vocational pollutants and of other aggravating factors, such as
pollen, aerosols, excessive humidity, stress, large meals, and ill contacts with
respiratory infections, is suggested. Adherence to medications as prescribed and
reporting of any problems with medications to the clinician are encouraged.
Recommended vaccinations include annual influenza vaccinations and the
pneumococcal vaccinations, provided there are no contraindications. 19,20
Nutritional counseling reinforces good nutrition with adequate calorie intake,
carbohydrate balance, and adequate hydration.5,21,22
Medical therapy involves optimal pharmacologic management of reversible
bronchospasm when it is present, including the use of bronchodilators such as
anticholinergics, methylxanthine derivatives, sympathomimetics, and combination
medications (Table 141-3). An improvement in FEV1 greater than 20% is
significant with bronchodilator use. Inhaled adrenergics and anticholinergics
appear to benefit many patients despite little objective evidence of improvement.

12

Training for proper administration of nebulizers or inhalers is important to

promote optimal medication deposition and to prevent inefficient use. Other
medications, such as expectorants, mucolytics, corticosteroids, antibiotics, and
disodium cromoglycate, are used along with humidification and brochial toilet, as
warranted, to prepare the patient for optimal participation in the therapeutic
exercise program.
Respiratory secretion management is critical for treatment and preventive care.
This involves training in the techniques of chest percussion, in postural drainage,
and with huffing ventilatory and airway secretion clearance devices. In addition,
autogenic drainage is a technique of breathing low tidal volumes between the
functional residual capacity and residual volume, followed by taking increasingly
larger tidal volumes and forced expirations to mobilize and to evacuate mucus.
Positive end expiratory pressure breathing techniques theoretically mobilize
secretions by coughing or forced expirations with alveolar pressure and volume
pushing behind mucous plugs. Flutter breathing with a flutter device applied to
the mouth uses two mucus-evacuating techniques: positive end expiratory
pressure and oscillation. Devices that provide mechanical vibration or oscillation
to the thorax include the Hayek Oscillator (Breasy Medical Equipment Inc.,
Stamford, Conn); ThAIRapy System (American Biosystem Inc., St. Paul, Minn);
and intrapulmonary percussive ventilator, which provides aerosolized medications
as high-flow percussive mini-bursts of air delivered to the airways (Percussionaire
Corp. Sandpoint, Idaho).
Early medical attention for respiratory tract infections is very important. Broadspectrum antibiotics and glucocorticoids should be considered. Home oxygen
therapy is used for oxygenation-impaired patients with lung disease if the PO 2 is
less than 60 mmHg and when it remains so far more than 2 months after an acute
exacerbation. This type of therapy decreases reactive pulmonary hypertension and
polycythemia, improves cognition, prolongs survival, and may decrease
hospitalizations. Transtracheal oxygen delivery avoids waste around the nose and
mouth, avoids the dead space of the nasopharynx, and prevents discomfort and

13

drying associated with nasal cannulas and facemasks. High-altitude travel may
require 0,5 L/min of additional supplemental oxygen.
Patients with COPD have a high incidence of sleep disordered breathing, that is,
obstructive and central apneas, for which continous positive airway pressure or
bilevel positive airway pressure can also be useful to provide some ventilatory
assistance, inspiratory muscle rest, and counter auto-positive end expiratory
pressure for hypercapnic COPD patients.

TABLE 141-3 Commonly Prescribed Medications

Category

Representative
Types

Main Respiratory
Clinical Effects

Main Side Effects

Bronchodilator

Anticholinergic
Sympathomimetic
s
Methylxanthine
derivatives
Combinations
Ipratropium

Relief of
bronchospasm by
relaxation of
bronchial smooth
muscle

See under specific

medicines

Relief of
bronchospasm by
relaxation of
bronchial smooth
muscle

Headache dry mouth

dizziness dyspnea
gastrointestinal
disturbance

Tiotropium

Relief of
bronchospasm

Anticholinergi
c

Tachycardia
palpitations
gastrointestinal distress
nervousness dry mouth
tremor
From Physician Desk Reference 61sted Montvale NI Medical Economics 2007

Predominant Ventilatory Impairment

Abdominal binders are useful for tetraplegic and thoracic level paraplegic spinal
cord patients to increase diaphragmatic excursion and vital capacity. However,
whereas inspiratory muscle strength or vital capacity in patients with primarily
ventilatory impairment, chest wall and lung mobilization has, and it is critical to

14

maintain sufficient excursion to allow the increased lung volumes necessary for
effective coughing.
Although bilevel positive airway pressure can be used by patients with primarily
ventilatory impairment, it is appropriate only for those who do not have sufficient
bulbar innervated muscle function for air stacking. When bilevel positive airway
pressure is used for these patients, polysomnographic titration is irrelevant. The
bilevel positive airway pressure inspiratory expiratory pressure span should be
sufficient to rest inspiratory muscles, that is, be 18 to 20 cm H 2O. Any patients
with bulbar-innervated muscle function for air stacking. When bilevel positive
airway pressure is used for these patients, polysomnographic titration is irrelevant.
The bilevel positive airway pressure inspiratory-expiratory pressure span should
be sufficient to rest inspiratory muscles, that is, be 18 to 20 cm H 2O. Any patients
with bulbar-innervated musculature sufficient for air stacking should use volumecycled ventilators rather than bilevel positive airway pressure machines.
Modifications are made for mask discomfort and air leakage. Portable volume
ventilators can provide greater inspiratory muscle assistance when it is needed,
such as for patients with obesity hypoventilation.5
Psycosocial counseling addresses symptoms of depression, anxiety, and stress as
well as social impediments to good progress. The goal is to break the influence of
these psycosocial issues on the cycle of respiratory decline.9
Mechanical insufflation-exsufflation is used to assist expiratory muscles to
increase cough flows to prevent pneumonia. It provides 10 L/sec of expiratory
flow directly to the airways through the upper airways or through tracheostomy
(CoughAssist, JH Emerson Co., Cambridge, Mass). Mechanically assisted
coughing is used in conjuction with an exsufflation-timed abdominal thrust,
combining the manual with the mechanical.17

15

Rehabilitation
An outpatient pulmonary rehabilitation program incorporates physical medicine
intervention, evaluation for respiratory equipment, and rehabilitation by an
interdisciplinary approach. The interdisciplinary team can include the patient,
medical and nursing staff, respiratory therapists, physical therapists, occupational
therapists, speech therapists, social workers, and a nutritionist. In addition,
psychology or psychiatry services, recreational therapists, and vocational
rehabilitation may be integrated as part of the team.
Exercise training for endurance, strength and function-specific activities is
prescribed (Table 141-4). The progress is monitored and modifications to the
prescription are made on the basis of the patients increasing aerobic capacity with
intensive exercise training. Scheduling for reevaluations of the prescription
depends on each patient; the early stages of the program and any acute medical
issues affect the need for possible prescription modifications. Frequency, duration,
intensity, and specificity are general exercise components. Frequency of exercise
is generally advised three to five times a week for training effect to be seen.
Patients should also be taught about their respiratory equipment.
Predominant Oxygenation Impairment
Carefully prescribed exercise provides the greatest benefits for reducing dyspnea
and respiratory rate and increasing exercise tolerance, maximum oxygen
consumption, 6 and 12 minute walk distance, activities of daily living, work
output, mechanical efficiency, and possibly gas exchange.23,27 Anxiety and
depression are also significantly decreased, and cognition and sense of well-being
are improved.
Low-intensity training can be prescribed on the basis of objective or subjective
measures. Objective measures involve calculation of the maximal oxygen
consumption or maximum heart rate. If open-circuit spirometry and metabolic cart

16

are available, specific target intensity may be 50% of peak rate of oxygen uptake.
Heart rate parameters may be most useful for patients with cardiac conditions.

TABLE 141-4 Types of Exercise

Type of Exercise
Ventilatory muscle training

Example
Inspiratory resistive exercise maximum
sustained ventilation, inspiratory resistive
loading, inspiratory threshold loading,
sustained hyperpnea

Strength training

Upper extremity exercise pulleys, elastic

bands, supervised circuit training,
weightlifting with low resistance
Lower extremity exercise supervised
circuit training, weightlifting with low
resistance

Endurance training

Upper extremity exercise unsupported

upper extremity activities ranging from
activities of daily living to athletic
activities, supervised arm cycling low
impact aerobics, pool therapy
Lower extremity exercise incremental
treadmill program, supervised walking
cycling and stair climbing program low
impact aerobics, pool therapy.

Several formulas are used. One is the desired exercise intensity multiplied by the
maximum predicted heart rate. Hence, if the desired exercise intensity is defined
as 60% of maximum predicted heart rate (HR), then
Target HR = 0,60 x (Hrmax = 220-age)
Another is the Karvonen formula. For the target heart rate range for 50% to 85%.
HR reserve = [(HRmax HRrest) x 0,50] + HRrest
= [(HRmax HRrest) x 0,85] + Hrrest

17

Initial targets can be 50% (range, 50% to 80%) of either objective measure or the
level tolerated by the patient.13
When objective measures are not applicable, as in the case of patients taking
negative chronotropic medications (e.g, blockers or calcium channel blockers)
and heart transplant recipients, subjective measures may be more predictive of
exercise tolerance. In addition, because patients are often limited by exertional
dyspnea, subjective measures may be more desirable.13
Subjective measures of exercise tolerance, such as the Borg rating of perceived
exertion scale or dyspnea rating scales, allow patients to guide the program on the
basis of their symptoms alone. The Borg rating of perceived exertion scale from 6
to 20 is linearly related to heart rate. This is illustrated by multiplying the chosen
scale number by 10 to obtain the estimated predicted heart rate. For example,
when the patient chooses the number 10 on the scale to describe exertion
symptoms, heart rate is estimated by the following equation:
10 x 10 = 100 (10)
The original Borg scale uses this method.13,28
Training specificity is determined by the patients goal for daily activities and
occupational pursuits. Daily activities in mobility and exercise programs are
tailored accordingly. Depending on the patients form on mobility and baseline
level of function, specific mobility and endurance exercise programs can include
walking, stair climbing, low-impact aerobics, stationary bicycling, and pool
activities. For mobility, work, and recreational pursuits, assistive devices to
improve daily activities may include wheelchair, walker, or cane. Strength training
increases function in daily activities, mobility, and specific occupation-related
tasks. Intermingled with endurance, strength, and task-specific training are energy
conservation techniques that provide the patient with

more energy efficient

methods to perform daily activities. Increased endurance for exercise can occur
independently of changes in ventilator muscle endurance.

18

Review of the training program is made with the patient and caregiver. A plan is
agreed on and is flexible to change, according to the patients tolerance. The
patient is made responsible for a progressive program to reinforce adherence and
independence.
Breathing retraining exercises are used with the goals of modifying the breathing
pattern to decrease the work of breathing and improving the cough mechanism.
Pursed lip breathing and diaphragmatic breathing decrease the respiratory rate,
coordinate the breathing pattern, and tend to prevent collapse of smaller bronchi.
Air shifting is performed several times per hour. It involves a deep inspiration that
is held with the glottis closed for 5 seconds. The air shifts to lesser ventilated
areas of the lung and may help prevent microatelectasis. The subsequent
expiration is through pursed lips. Pursed lip breathing aids in relaxation as well.
Other relaxation exercises, such as Jacobson exercises and biofeedback, can be
used to decrease tension and anxiety.29,30
For hypercapnic patients, interspersing periods of respiratory muscle rest with
exercise of specific respiratory muscle groups is a principle of pulmonary
rehabilitation. Rest can be achieved by overnight useof nasal bilevel positive
airway pressure. Improved daytime gas values, increased vital capacity, decreased
fatigue, and increased well-being have been reported in such programs.

TABLE 141-5 Pulmonary Hygiene Options 11,14,43

Inhalers
Bronchodilators
Inhaled steroid
Leukotriene inhibitors
Mucolytics
Methods of airway secretion elimination
Oral, nasal, or transtracheal suctioning
Chest percussion and postural drainage
Positive expiratory pressure breathing
Flutter mucus clearance devices

19

Mechanical vibration devices to the chest wall

Intrapulmonary percussive ventilation with aerosolized medications
Mechanical insufflations-exsufflation applications
Autogenic drainage
Manual assisted cough
Abdominal binder

After the acute rehabilitation period, continued surveilance and attention to

abstinence from smoking, bronchial hygiene (Table 141-5), breathing retraining,
physical reconditioning, oxygen therapy, and airway secretion mobilization have
been shown to reduce hospital admissions, length of hospital stays, and cost. The
benefits of pulmonary rehabilitation on exercise performance and quality of life
are greatest during the first year and last up to 5 years.26,27,35-37
Predominant Ventilatory Impairment
The primary interventions for patients with generalized muscle weakness are the
use of respiratory muscle aids and facilitation of habilitation to disability rather
than rehabilitation. Cough peak flows greater than 160 L/min are the minimum
needed for airway secretion clearance and hence indicate safety for removal of
tracheostomy tube whether the patient is ventilator dependent or not. Ninety
percent of episodes of acute respiratory failure are caused by ineffective coughing
during otherwise benign upper respiratory tract infections; therefore, when
assisted peak cough flows have decreased to less than 270 L/min, patients are
prescribed oximeters and trained in air stacking of consecutively delivered
volumes of air provided through mouth or nasal interfaces from a manual
resuscitator (ambu bag) to improve cough flows.38 they also taught manually
assisted coughing (abdominal thrusts timed to glottic opening after maximal lung
insufflation). They are introduced to mechanical insufflation-exsufflation
(CoughAssist) provided at +35 to +50 to -35 to -50 cm H 2O pressure drops, with
abdominal thrusts applied during exsufflations. Patients must have rapid (less than

20

2-hour) access to portable volume ventilators, CoughAssist, and various

mouthpieces and nasal interfaces when they develop respiratory muscle aidoximetry protocol to prevent respiratory failure, patients and care providers are
instructed to use continuous pulse oxyhemoglobin saturation (SpO2) monitoring at
the first sign of upper respiratory tract infection. Any decreases in SpO 2 of less
than 95% indicate either hypoventilation or the presence of airway mucus
accumulation that must be cleared to prevent atelectasis, pneumonia, and
respiratory failure. Patients learn to use noninvasive ventilation or manually and
mechanically assisted coughing to maintain sufficient alveolar ventilation and
airway secretion clearance to keep SpO2 at 95% or higher and thereby avoid
respiratory failure. They are also told to use SpO 2 monitoring whenever fatigued,
short of breath, or ill. They are instructed to use manually and mechanically
assisted coughing, as needed, to maintain normal SpO2 at all times.
When symptomatic, nocturnal SpO2 decreases below 95% are common, and
patients are encouraged to use nocturnal nasal intermittent positive-pressure
ventilation for the first time to assist lung ventilation during chest infections and
need it continuously without ever requiring hospitalization, in many cases despite
having no measurable vital capacity for decaded.35,36

Procedures
Training in the use of nebulizers, hand-held inhalers, chest percussion and
postural drainage, and respiratory equipment is important during the outpatient
pulmonary rehabilitation program. Self-directed patients should be independent in
training their ventilators and CoughAssist devices according to time of day and
clinical situation.

Surgery
Lung volume reduction surgery is performed for patients with severe functionlimiting emphysema with the goal of improving gas exchange, exercise capacity,

21

lung function, and quality of life. Candidates for lung volume reduction surgery,
patients who have had lung volume reduction surgery, and lung transplantation
and post-lung transplantation patients may be prescribed an inpatient or outpatient
pulmonary rehabilitation program, depending on the patients goals and medical
stability.37,38
Among patients with pulmonary dysfunction who have significant nutritional
deficiencies by oral intake, alternative routes for nutrition, such as percutaneous
gastrostomy tube, are considered.
Patients with respiratory muscle impairment are taught the use of inspiratory and
expiratory muscle aids (i.e., mouthpiece and nasal noninvasive mechanical
ventilation and mechanically assisted coughing) before surgery so that they can be
extubated to the use of these aids after surgery, even when they are not capable of
independently ventilating their lungs.39 tracheostomy is needed only when bulbarinnervated muscle dysfunction is so severe that patients aspirate saliva to the
extent that SpO2 cannot be maintained at 95% or higher. In general, this occurs
only for the patients with advanced bulbar amyotropic lateral sclerosis.40

POTENTIAL DISEASE COMPLICATIONS

Potential disease complications play a significant role in the outpatient pulmonary
rehabilitation prescription. In generating a prescription, it is important to consider
the patients specific diagnosis and potential complications. Complications of
chronic respiratory disease depend on the effects of progression of the primary
pathologic process and natural aging on respiratory muscle function and lung
tissues. Nutritional deficits, psychosocial issues, and comorbidities can also play
an important role.

Predominant Oxygenation Impairment

Patients with primarily oxygenation impairment due to lung or airways disease
often have intermittent exacerbations with episodes of acute respiratory failure.

22

These often require acute hospitalization and invasive management. They are
largely caused by inability to mobilize peripherally trapped airway secretions.
There are many secretion mobilization systems to help mobilize airway secretions,
but there is no clear evidence that one system works better than any other. The
least expensive and simplest methods to supplement airway secretion mobilization
efforts, such as use of a flutter valve, positive expiratory pressure mask, and chest
vibrators, are probably as effective as expensive chest vibrating and oscillating
devices.41 supplemental methods of respiratory therapeutic secretion mobilization
that can be taught include chest percussion and postural drainage, huffing, and
active cycle of breathing. The last is the most inexpensive technique of airway
secretion mobilization because no assistive device is used. The patient simply
breathes slowly and shallowly at lung volumes well below functional residual
capacity and, once reaching it, take a deep breath and huffs out secretions.
Other important strategies for these patients are to administer and to monitor
compliance with antibiotics, bronchodilators, oxygen, mucolytics, and other
medications.

Predominant Ventilaroy Impairment

The evaluation for long-term airway protection with a tracheostomy is a
common clinical scenario. However, because patients with no measurable vital
capacity or any volitional skeletal muscle movement for more than 50 years do
not require tracheostomy,42,43 obviously one is not needed for inspiratory or
expiratory muscle failure but rahter for failure of bulbar-innervated musculature
alone. Once aspiration of saliva cause the SpO 2 baseline value to decrease and to
remain less than 95%, 90% of patients undergo tracheotomy or are deceased
within 2 months.40 this, however, occurs only for patients with advanced bulbar
amyotropic lateral sclerosis, for children with type 1 spinal muscular atrophy
without sufficient home care,44 for occasional patient with facioscapulohumeral
muscular dystrophy, and very few others. Such patients almost invariably have

23

maximum assisted peak cough flows of less than 160 L/min and are incapable of
air stacking because of failure of glottic closure.45

POTENTIAL TREATMENT COMPLICATIONS

Potential treatment complications can result from oxygen toxicity, barotrauma
from ventilator use, comorbidities such as concominant cardiac or atherosclerotic
peripheral vascular disease, and pharmacologic treatment. Routine evaluation of a
patients medication profile by the treating clinician is necessary. Immobility due
to muscle weakness or acute illness can also exacerbate pulmonary secretion stasis
and cause deep venous thromboses, cardiac deconditioning, skin ulceration, bone
decalcification, and muscoskeletal contractures. Each individuals progress with
mobilization, exercise, and daily activity facilitation programs is monitored, and
prescriptions are modified accordingly.
References
1. Hodgkin J, Farrell M, Gibson S, et al. American Thoracic Society. Medical
Section of American Lung Association. Pulmonary rehabilitation. Am Rev
Respir Dis 1981;124:663-666.
2. American Thoracic Society. Pulmonary rehabilitation-1999. Am J Respir Crit
Care Med 1999;159:1666-1682.
3. American College of Chest Physicians and American Association of
Cardiovascular and Pulmonary Rehabilitation: joint ACCP/AACVPR
evidence-based guidelines. Chest 1997;112:1363-1396.
4. Holden D, Stelmach KD, Curtis PS, et al. The impact of a rehabilitation
program on functional status of patients with chronic lung disease. Respir
Care 1990;35:332-341.
5. Bach JR. Rehabilitation of the patient with respiratory dysfunction. In DeLisa
JD, ed. Rehabilitation Medicine: Principles and Practice. Philadelphia,
Lippincott-Raven, 2005:1843-1866.
6. Higgins MW, Thom T. Incidence, prevalence, and mortality: intra and
intercountry differences. In Hensley MJ, Saunders NA, eds. Clinical
Epidemiology of Chronic Obstructive Pulmonary Disease. New York Marcel
Dekker, 1989:23-43.
7. Fienleib M, Rosenberg HM, Collins JG, et al. trends in COPD morbidity and
mortality in the United States. Am Rev Respir Dis 1989;140:S9-S18.
8. Koga T, Watanabe K, Sano M, et al. The breathing intolerance index for
ventilator use. Am J Phys Med Rehabil 2006;85:24-30.

24

9. Smoller JW, Pollack MH, Otto MW, et al. Panic anxiety, dyspnea and
respiratory disease: theoretical and clinical considerations. Am J Respir Crit
Care Med 1996;154:6-17.
10. Bach JR, Rajaraman R, Ballanger F, et al. Neuromuscular ventilator
insufficiency: the effect of home mechanical ventilator use vs. oxygen
therapy on pnuemonia and hospitalization rates. Am J Phys Med Rehabil
1998;77:8-19.
11. American College of Sports Medicine. Guidelines for Exercises Testing and
Prescription, 5th ed. Philadelphia, Williams & Wilkins, 1995.
12. Jones NL. Current concepts: new tests to assess lung function. N Engl J Med
1975;293:541-544.
13. Jones NL, Campbell EJM. Clinical Exercise Texting, 2nd ed. Philadelphia,
WB Saunders, 1982:158.
14. Guyatt GH, Thompson P.J, Berman LB, et al. How should we measure
function in patients with chronic heart and lung disease? J Chronic Dis
1985;38:517524.
15. American Association of Cardiovascular and Pulmonary Rehabilitation
Programs, 2nd ed. Champaign, Ill, Human Kinetics, 1998.
16. Carlson DJ, Ries AL, Kaplan RM. Prediction of maximum exercise tolerance
in patients with COPD. Chest 1991;100:307-311.
17. Gomez-Merino E, Bach JR. Duchenne muscular dystrophy: prolongation of
life by noninvasive respiratory muscle aids. Am J Phys Med Rehabil
2002;81:411-415.
18. Camili AE, Burrows B, Knudson RJ, et al. Longitudinal changes in forced
expiratory volume in one second in adults. Effects of smoking and smoking
cessation. Am Rev Respir Dis 1987; 135:794-799.
19. Prevention of pneumococcal disease: recommendations of the Advisory
Committee on Immunization Practices. MMWR Recomm Rep 1997;46(RR8):1-24.
20. Bridges CB, Winquist AG, Fukuda K, et al. Prevention and control of
influenza: recommendation of the Advisory Committee on Immunization
Practices. MMWR Recomm Rep 2000;49(RR-3):1-38.
21. Wilson DO, Rogers RM, Wright EC, Anthonisen NR. Body weight in chronic
obstructive pulmonary disease. Am Rev Respir Dis 1989;139:1435-1438.
22. Askanazi J, Weissman C, Rosenbaum SH, et al. Nutrition and the respiratory
system. Crit Care Med 1982;10:153-172.
23. Gozal D. Nocturnal ventilatory supports in patients with with cystic fibrosis:
comparison with supplemental oxygen. Eur Respir J 1997;10:1999-2003.
24. Giminez M, Servera E, Vergara P, et al. Endurance training in patients with
chronic obstructive pulmonary disease: a comparison of high versus moderate
intensity. Arch Phys Med Rehabil 2000;81:102-109.

25

25. Carter R, Nicotra B, Clark L, et al. Exercise conditioning in rehabilitation of

patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil
1988;69:118-122.
26. Troosters T, Gosselink R, Decramer M. Short and long-term effects of
outpatients rehabilitation in patients with chronic obstructive pulmonary
disease: a randomized trial. Am J Med 2000;109:207-212.
27. Make B. Pulmonary rehabilitation and outcome measure. In Baum GL, Crapo
JD, Celli BR, Karlinsky JB, eds. Textbook of Pulmonary Diseases, 6 th ed.
Philadelphia, Lippincott-Raven, 1998:987-1006.
28. Noble BJ, Borg GA, Jacobs I, et al. A category-ratio perceived exertion scale:
relationship to blood and muscle lactates and heart rate. Med Sci Sports Exerc
1983;15:523-528.
29. Reina-Rosenbaum R, Bach JR, Penek J. The cost/benefits og outpatients
based pulmonary rehabilitation. Arch Phys Med Rehabil 1997;78:240-244.
30. Khan AU. Effectiveness of biofeedback and counterconditioning in the
treatment of bronchial asthma. J Psychosom Res 1977;21:97-104.
31. Elliot MW, Mulvey D, Mozham J, et al. Domiciliary nocturnal nasal
intermittent positive pressure ventilation in COPD: mechanisms underlying
changes in arterial blood gas tensions. Eur Respir J 1991;4:1044-1052.
32. Gay P, Hubmayr RD, Stroetz RW. Efficacy of nocturnal nasal positive
pressure ventilation combined with oxygen therapy and oxygen monotherapy
in patients with severe COPD. Am J Respir Crit Care Med 1996;154:353-358.
33. Hudson LD, Tyler ML, Petty T. Hospitalization need during an outpatient
rehabilitation program for chronic airway obstruction. Chest 1976;70:606610.
34. Roselle S, DAmico FJ. The effect of home respiratory therapy on hospital readmission rates of patients with chronic obstructive pulmonary disease.
Respir Care 1990;35:1208-1213.
35. Holle RH, Williams DV, Vandree JC, et al. Increased muscle efficiency and
sustained benefits in an outpatients community hospital-based pulmonary
rehabilitation program. Chest. 1988;94:1161-1168.
36. Ilowite J, Niederman M, Fein A, et al. Can benefits seen in pulmonary
rehabilitation be sustained long term? Chest 1991;!00:182.
37. Mall RW, Medieros M. Objective evaluation of result of a pulmonary
rehabilitation program in a community hospital. Chest 1988;94:1156-1160.
38. Bach JR, Gonzalves M, Paez S. Expiratory flows maneuvers of patients with
neuromuscular diseases. Am J Phys Med Rehabil 2006;85:105-111.
39. Bach JR, Sabharwal S. High pulmonary risk scoliosis surgery: role of
noninvasive ventilation and related techniques. J Spinal Disord Tech
2005;18:527-530.
40. Bach JR, Bianchi C, Aufiero E. Oximetry and prognosis in amyotrophic
lateral sclerosis. Chest 2004;126:1502-1507.

26

41. Hardy KA. A review of airways clearance: new techniques, indications, and
recommendations. Respir Care 1994;39:440-455.
42. Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via
the mouth as an alternative to tracheostomy for 257 ventilator users. Chest
1993;103:174-182.
43. Bach JR. ed. Noninvasive Mechanical Ventilation . Philadelphia, Hanley &
Belfus, 2002.
44. Bach JR, Baird JS, Plosky D, et al. Spinal muscular atrophy type 1:
management and outcomes. Pediatr Pulmonol 2002;34:16-22.
45. Kang SW, Bach JR. Maximum insufflation capacity. Chest 2000;118:61-65.

141
Rehabilitasi Paru

27

John R. Bach, MD

Synonyms
Tidak ada

ICD-9 Codes
E0450 Ventilasi mekanik invasif
E0461 Ventilasi mekanik noninvasif
E0482 Insuflasi dan eksuflasi mekanik

28

DEFINISI
Rehabilitasi paru didefinisikan sebagai seni dalam praktik kedokteran dimana
secara individual, seseorang ditangani secara menyeluruh melalui diagnosis yang
akurat, terapi, dukungan emosional, dan edukasi baik pada fisiopatologi maupun
psikopatologi penyakit-penyakit paru dengan tujuan untuk mengembalikan
kapasitas maksimal paru fungsional yang masih memungkinkan pada kelainan
paru yang diderita dan pada semua situasi.

1-2

Tujuan rehabillitasi paru adalah

untuk memperbaiki keadaan dispneu dan keadaan dekondisi, mengoptimalkan

sekresi pernapasan dan fungsi otot pernapasan, mengurangi kejadian rawat inap
dan komplikasi paru, mengatasi faktor-faktor psikososial, memfasilitasi
rehabilitasi dan hubungan dengan masyarakat, dan meningkatkan fungsi
kemandirian.1-4 Pasien rawat jalan yang dapat menjalani rehabilitasi paru yaitu
pasien anak dan dewasa yang berkeinginan untuk mendapat manfaat seperti yang
telah disebutkan sebelumnya, pasien yang mengalami disfungsi otot pernapasan
atau disfungsi paru yang mempengaruhi aktivitas dan harapan hidup dan pasien
yang kondisinya cukup stabil untuk menjalani manajemen rawat jalan.

Perbandingan antara Proses Patologis, Penanganan, dan Hasil

Pada perkembangan terapi untuk pasien yang menjalani terapi rehabilitasi paru,
sangat penting untuk membedakan antara disfungsi paru karena penyakit paru
atau saluran napas atau gangguan oksigenasi maupun gangguan pada ventilasi
alveolar dengan keadaan parenkim paru yang normal. Pasien dengan gangguan
oksigenasi seringkali mengalami hipoksia dengan kadar CO2 normal. Pasien
dengan gangguan ventilasi mempertahankan CO2 dari disfungsi otot, aktivitas
yang berlebihan, atau hipoventilasi sentral. Klasifikasi ini memungkinkan klinisi
untuk memfokuskan terapi rehabilitasi paru yang tepat untuk setiap pasien.
Selanjutnya, bab ini akan menguraikan terapi berdasarkan klasifikasi di atas.
Kondisi yang berhubungan dengan gangguan oksigenasi dijabarkan pada tabel
141-1. Jika pada suatu kondisi atau beberapa kondisi saling mendominasi, ketika

29

terjadi tumpang tindih, maka terapi yang diberikan harus mencakup untuk semua
kondisi tersebut. 5
Hasil yang diharapkan dari terapi rehabilitasi paru yaitu penurunan angka kejadian
rawat inap, penurunan morbiditas dan mortalitas, penurunan gejala, peningkatan
kualitas

hidup,

peningkatak

aktivitas

fungsional,

peningkatan

kondisi

neuropsikologis, peningkatan kemampuan kerja, dan pemanfaatan efektif dari

teknologi pendukung pernapasan. Setiap terapi yang diberikan merupakan terapi
spesifik untuk setiap individu dan disesuaikan dengan kondisi pasien.

Insidensi
Prevalensi penyakit paru obstruktif kronis (PPOK) pada kelompok dewasa sekitar
4% sampai 6% pada laki-laki, dan !% sampai 3 % pada perempuan. Berdasarkan
National Health Interview Survey tahun1996, sekitar 14 juta orang menderita
bronkitis kronik. PPOK merupakan penyebab kematian keempat di US dan
penyebab tersering pada gangguan oksigenasi.6,7
Gagal napas yang berhubungan dengan kelemahan otot-otot pernapasan
(gangguan ventilasi) terjadi pada sekitar 1 dari 800 orang pasien dengan penyakit
neuromuskular. Meskipun demikian, baik gagal napas akut maupun kronik juga
dapat berasal dari disfungsi otot pernapasan yang berhubungan dengan penyakit
sistem saraf pusat seperti penyakit serebrovaskular dan cedera otak. Hampir 50%
pasien rawat jalan yang dianjurkan menggunakan ventilasi mekanik didiagnosis
dengan gangguan ventilasi karena prognosisnya lebih baik daripada yang
mengalami gangguan oksigenasi. Telah dilakukan berbagai upaya untuk
menentukan indikasi diperlukannya rehabilitasi paru dan penggunaan terapi
ventilator yang tepat untuk pasien rawat jalan.8

Table 141-1 Kondisi yang berhubungan dengan gangguan oksigenasi dan

gangguan ventilasi
Keadaan dengan kondisi utama gangguan oksigenasi
Penyakit paru obstruktif kronis
Asma

30

Emfisema dan emfisema yang diakibatkan operasi reduksi volume paru

Fibrosis kistik
Bronkiektasis
Penyakit restriktif (contohnya. Fibrosis paru, penyakit parenkim primer)
Keadaan dengan kondisi utama gangguan ventilasi
Miopati
Duschene muscular dystrophy
Becker muscular dystrophy
Limb-girdle muscular dystrophy
Emery-Dreifuss muscular dystrophy
Facioscapulohumeral muscular dystrophy
Congenital, autosomal recessive, myotonic muscular dystrophy
\

Generalized nondystrophic myopathies

Inflammatory Bowel Disease-Associated (Chron Disease and Ulcerative Colitis)

Arthritis Miopati kongenital, metabolik, atau inflamasi
Myasthenia Gravis
Mixed connective tissue disease myopathies
Kelainan neurologis
Amyotrophic lateral sclerosis
Disfungsi medulla spinalis
Atrofi otot spinal
Penyakit motor neuron
Poliomyelitis
Hereditary sensory motor neuropathies
Neuropati nervus phrenicus, sindrom Guillain-Barre
Multiple sclerosis
Friedreich ataxia

31

Mielopati
Botulisme
Sleep-disordered breathing
Sindrom hipoventilasi sentral dan kongenital
Hipoventilasi yang berhubungan dengan mikroangiopati diabetikum
Down syndrome
Familial dysautonomia
Muskuloskeletal
Deformitas dinding thoraks
Kifoskoliosis
Ankylosing spondylitis
Osteogenesis imperfecta
Rigid spine syndrome
Kongenital spondyloepiphyseal dysplasia
Penyakit paru restriktif
Hipoventilasi obesitas
Penyakit pada pleura dan dinding dada
Tuberkulosis
Penyakit Milroy

GEJALA
Gejala dari gangguan oksigenasi meliputi dispneu saat beraktivitas atau dalam
kegiatan sehari-hari, cemas, depresi, sakit kepala, dan sulit berkonsentrasi. 9 Pasien
dapat mengalami produksi sputum kronik, batuk, mengi, nyeri dada yang
bervariasi sesuai siklus pernapasan, penurunan berat badan, orthopneu, gangguan
tidur, dan kelemahan daya tahan. Kumpulan gejala alergi juga mungkin terlihat.

32

Gejala lain yang mungkin berhubungan misalnya demam dan hemoptisis dapat
terjadi, seperti pada pasien dengan bronkiektasis.
Pasien dengan kondisi utama gangguan ventilasi umumnya mengeluh kelelahan.
Keluhan lain dapat berupa dispneu saat aktivitas, penurunan berat badan,
gangguan tidur, kelemahan daya tahan, sakit kepala pada pagi hari, dan
ketidakstabilan emosi. Untuk pasien yang menggunakan kursi roda atau skuter,
gejala minimal sangatlah umum terjadi sampai kecemasan atau ketidakmampuan
untuk tidur muncul selama infeksi saluran napas berulang sampai tanda gagal
napas.10 Kondisi gagal napas akut umumnya diderita oleh pasien dengan
kelemahan neuromuskular dengan batuk yang tidak efektif.

PEMERIKSAAN FISIK
Gangguan Oksigenasi
Bagi pasien dengan penyakit paru atau saluran pernapasan, pemeriksaan fisik
tergantung pada proses patologis yang mendasarinya (lihat tabel 141-1). Pada
pasien dengan PPOK, umumnya ditemukan produksi sputum yang masif,
penggunaan otot bantu pernapasan dan barrel chest. Pada auskultasi ditemukan
mengi, ronkhi, atau suara napas hipersonor. Evaluasi dengan pulse oksimeter
selama fase istirahat dan aktivitas sering menunjukkan perburukan gangguan
oksigenasi saat beraktivitas.6

Gangguan Ventilasi
Semua penyakit neuromuskular umum menyebabkan derajat kelemahan
kemampuan inspirasi (bernapas), ekspirasi (batuk), dan inervasi otot bulbar
(bicara, menelan, dan proteksi udara) yang bervariasi. Pasien dapat mengalami
peningkatan laju pernapasan, pernapasan dangkal, pernapasan diafragma atau
paradoksal, penggunaan otot bantu pernapasan tambahan, napas cuping-hidung,
sianosis peribuccal atau sianosis sentral, pucat, pengeluaran air liur, kesulitan
dalam mengontrol pernapasan, disfagia, atau bicara sengau.

33

KETERBATASAN FUNGSI
Level dasar dari fungsi tubuh, termasuk toleransi latihan dan kemampuan untuk
melakukan aktivitas sehari-hari, dapat sangat berkurang. Sangat mungkin terdapat
kesulitan dalam mengontrol sekresi pernapasan, kesulitan mengunyah dan
menelan makanan, dan penurunan interaksi social. Banyak pasien memerlukan
penggunaan ventilator guna mengistirahatkan otot inspirasi untuk menghindari
atau untuk meringankan gejala pada saluran napas. Aktivitas sehari-hari akan
sangat terganggu akibat disfungsi umum otot pernapasan atau gangguan spesifik
pada otot pernapasan. Sebagai contoh, takipneu menyebabkan pasien kekurangan
waktu untuk mengunyah dan menelan. Keadaan ini menyebabkan malnutrisi yang
lebih lanjut memperburuk fungsi pernapasan. Manajemen dengan bantuan
ventilator berbentuk corong sederhana dapat membantu mengurangi takipneu dan
berefek pada perbaikan gizi dan meningkatkan daya tahan (Gbr. 141-1).

STUDI DIAGNOSTIK
Uji diagnostik dapat membedakan antara keadaan pasien dengan kondisi utama
gangguan ventilasi dan gangguan oksigenasi. Pasien dengan gangguan oksigenasi,
setidaknya memiliki satu dari gejala berikut ini: keterbatasan pernapasan dengan
latihan pada 75% prediksi maksimal konsumsi oksigen, obstruksi jalan napas
ireversibel dengan volume ekspirasi paksa dalam 1 detik (FEV 1) kurang dari 200
mL atau rasio FEV1 berbanding kapasitas vital paksa (FEV1/FVC) kurang dari
60%; atau penyakit pembuluh darah paru dengan kapasitas difusi CO kurang dari
80% dari prediksi.
Pasien dengan gangguan ventilasi, setidaknya memiliki satu dari gejala berikut
ini: hiperkapnia, keterbatasan pernapasan dengan latihan pada 75% prediksi
maksimal konsumsi oksigen normal; atau penurunan kapasitas vital dengan rasio
FEV1/FVC normal sampai tinggi, penurunan cough peak flow, penurunan tekanan
maksimum inspirasi dan ekspirasi, dan pengukuran volume paru yang rendah
(misalnya, kapasitas total paru, kapasitas residu fungsional, dan volume residu).
Banyak pasien dengan gejala ini yang mengalami deformitas dinding dada. Sangat

34

penting untuk mengukur cough flow tanpa atau dengan bantuan untuk pasien
dengan kondisi tersebut karena seringkali terjadi gagal napas sebagai akibat dari
batuk yang inefektif.10 Cough flows dengan bantuan dihasilkan dari penumpukan
volume udara yang dihantarkan melalui resusitator manual dan diubah menjadi
volume maksimal yang dapat diterima oleh glottis yang tertutup. Pada keadaan
ini, dorongan abdominal dihantarkan sebagai respon dengan pembukaan glottis.
Udara yang dikeluarkan diukur sebagai cough flow pada alat ukur peak flow.

GAMBAR 141-1. Seorang laki-laki berusia 17 tahundengan atrofi otot spinal ringan tipe 1yang
secara terus menerus menggunakan ventilator berbentuk corong pada siang hari dan sebuah nasal
interface saat tidur.

Uji Klinis untuk Menentukan Pasien yang Perlu Menjalani

Rehabilitasi dengan Kondisi Utama Gangguan Oksigenasi
Pasien yang merupakan target ideal untuk dilakukan rehabilitasi paru yaitu pasien
yang masih dapat berjalan beberapa blok namun sudah terdeteksi mengalami
penurunan toleransi dalam aktivitas setiap tahunnya atau pasien yang baru
membutuhkan penanganan medis untuk gejala paru atau komplikasi yang
dideritanya.

35

Uji latihan klinis dapat menentukan sejauh mana pasien mengalami gangguan
fungsional akibat penyakit paru yang diderita. Hal ini dapat membantu diagnosis
dan menentukan tahanan fungsional dan kapasitas untuk melakukan aktivitas,
menentukan faktor yang membatasi aktivitas, dan menentukan latihan yang tepat
sesuai dengan gejala.11-13 Uji latihan klinis memudahkan klinisi untuk menentukan
kelainan yang diderita berasal dari paru, jantung, atau bronkospasme yang
disebabkan oleh latihan.13 Dua diagnosis terakhir dan bahkan gejala paru restriktif
seringkali disalahartikan sebagai PPOK. Baik dikerjakan sebelum maupun
sesudah program rehabilitasi, uji latihan klinis digunakan menilai kemajuan
pasien.
Tanda vital, elektrokardiografi, konsumsi oksigen, produksi karbon dioksida, hasil
pernapasan, kesamaan ventilasi, ventilasi permenit, dan laju metabolisme dinilai
saat uji latihan klinis dilakukan, baik dengan menggunakan treadmill, sepeda
statis, atau ergometer ekstrimitas atas. Semua pasien menjalani tes berjalan selama
3, 6, atau 12 menit. Pasien diinstruksikan untuk menambah kecepatan dan durasi
secara berkala pada tes berjalan. 11-15 Uji latihan klinis tetap ditingkatkan sampai
konsumsi oksigen gagal untuk mencapai kenaikan; nadi maksimal sesuai umur
tercapai; atau terdapat perubahan pada gambaran elektrokardiografi, nyeri dada,
dispneu berat, atau kelelahan. Oksimetri digunakan untuk menggambarkan
keadaan yang membutuhkan oksigen tambahan selama rekondisi berlangsung
(pulse saturasi oksihemoglobin [SpO2] SpO2 < 90% sampai 95%) atau pada
keadaan (PO2 < 60 mm Hg) yang berlangsung lama. Jika uji metabolic tidak
tersedia, toleransi latihan maksimal dapat diperkirakan dari data paru fungsional.
11-13, 16

Gangguan Ventilasi
Pasien dengan kondisi utama gangguan ventilasi menjalani tes spirometri untuk
menentukan kapasitas vital saat duduk, posisi supinasi dan kapasitas insuflasi
maksimal, unassisted dan assisted cough peak flows dengan menggunakan peak
flow meter, pengukuran volume tidal karbon dioksida, dan pulse oximetry.17

36

Selisih antara kapasitas vital pada posisi duduk dengan posisi supinasi yang lebih
dari 20% merupakan indikasi kuat terjadinya kelemahan diafragma dan disfungsi
pada otot bantu pernapasan. Ketika kapasitas vital kurang dari 80% dibandingkan
normal, pasien dilatih untuk melakukan teknik insuflasi maksimal, seperti air
stacking yang telah disebutkan sebelumnya. Air stacking yang dilakukan secara
manual maupun mekanik selama proses bantuan batuk dimaksudkan untuk
mempertahankan sekresi klirens pernapasan yang adekuat dan mencegah
atelektasi dan pneumonia. Cough peak flows yang kurang dari 270 L/menit
mengindikasikan untuk dilakukan inisiasi pemberian protokol oximetryrespiratory aid yang akan dijabarkan kemudian. Gejala hipoventilasi nokturnal,
end-tidal CO2 diatas 45 mm Hg, atau desaturasi oksigen siang atau malam hari
dibawah 95% mengindikasikan percobaan pemberian ventilasi tekanan positif
berulang noninvasif. 17

Differential Diagnosis
Dekondisi
Disfungsi jantung
Infeksi paru
Obesitas
Status fungsional
Tujuan terapi pada pasien

PENATALAKSANAAN
Memilih tujuan terapi
Teknik dan alat pengeluaran sekresi pernapasan

Awal

Program penghentian merokok

Gangguan
Oksigenasi
Program latihan:
Latihan
ventilasi
Tatalaksana
utama
dalamotot
rehabilitasi paru terangkum dalam tabel 141-2. Pasien
Latihan ketahanan dan kekuatan
dan pemberi pelayanan diedukasi mengenai perawatan dan pencegahan.
Latihan pernapasan
TABLE
141-2 Rehabilitasi paru
Teknik pernapasan alternatif
Program rehabilitasi paru dasar
Teknik penyimpanan energi
Penilaian awal terhadap:
Modalitas terapi
Proses penyakit respiratorik
Kelainan
medisalat
yang
mendasari
Penggunaan
mobilitas
yang
adaptif
Kelainan medis umum
Konseling psikososial
Edukasi pasien dan pemberi pelayanan
Program maintenance

37

Pengehentian konsumsi rokok sangat ditekankan untuk mengurangi produksi

dahak kronis dan menurunkan nilai FEV1, ke level nonperokok.18,19 Disarankan
menghindari polusi dan faktor pengganggu lainnya seperti serbuk, aerosol,
kelembaban berlebihan, stres, makanan berat dan kontak dengan infeksi
pernafasan. Kepatuhan dalam menjalani pengobatan dan konsultasi bila ada
masalah kepada klinisi snagat diharapkan. Vaksinasi disarankan termasuk
vaksinasi influenza dan pneumokokkus, jika tidak ada kontraindikasi.19,20
Pengaturan gizi dengan nutrisi yang baik dan intake kalori, keseimbangan
karbohidrat, dan hidrasi yang adekuat. 5,21,22
Terapi klinis termasuk optimalisasi dalam manajemen farmakologis jika terjadi
bronkospasme, termasuk penggunaan bronkodilator seperti antikolinergik,
derivate metilxantin, simpatomimetik, dan pengobatan kombinasi (Tabel 141-3).
Peningkatan FEV1 lebih dari 20% sangat signifikan dengan penggunaan
bronkodilator. Penggunaan adrenergik dan antikolinergik secara inhalasi

38

menunjukkan manfaat pada banyak pasien meskipun bukti objektif yang

menyertai sedikit. Pelatihan untuk pemberian nebulisasi yang tepat sangat penting
untuk mencapai pengobatan yang obtimal dan menghindari penggunaan yang
tidak efisien. Pengobatan lain seperti ekspektoran, mukolitik, kortikosteroid,
antibiotic, dan disodium cromoglicat digunakan sesuai dengan kelembaban dan
kebersihan bronchial yang telah terjamin untuk mempersiapkan pasien menjalani
terapi latihan.
Manajemen sekresi pernapasan sangat penting untuk pengobatan dan proses
penyembuhan pasien. Hal ini menyangkut teknik latihan perkusi dada, drainase
postural, ventilasi minimal dan alat klirens sekresi pernapasan. Selain itu, drainase
autogenik adalah teknik bernapas dengan menggunakan volume tidal rendah
antara kapasitas residual fungsional dan volume residu yang diikuti oleh
pengambilan volume tidal yang semakin besar dan ekspirasi paksa untuk
memobilisasi dan mengeluarkan mukus. Tekanan positif dan ekspirasi secara
teoritis memobilisasi sekresi dengan batuk atau ekspirasi paksa dengan tekanan
alveolar dan volume yang mendorong dari bagian belakang mucus. Pernapasan
getar dengan bantuan alat getar digunakan pada mulut menggunakan dua teknik
evakuasi mucus: tekanan positif dan ekspirasi serta isolasi.Alat yang dapat
digunakan yaitu Hayek Oscillator (Breasy Medical Equipment Inc., Stamford,
Conn); ThAIRapy System (American Biosystem Inc., St. Paul, Minn); and
ventilator perkusif intrapulmoner, yang mencakup pengobatan aerosol sebagai
aliran perkusif yang kuat dengan bentuk spray udara yang masuk ke saluran
pernapasan (Percussionaire Corp. Sandpoint, Idaho).
Deteksi dini pada adanya infeksi saluran pernapasan sangatlah penting. Pemberian
antibiotik spectrum luas dan glukokortikoid dapat dipertimbangkan. Oksigen
terapi rumahan dapat digunakan pada pasien denganpenyakit paru jika PO 2 kurang
dari 60 mmHg dan telah berlangsung selama lebih dari 2 bulan setelah eksaserbasi
akut. Jenis terapi ini menurunkan hipertensi pulmonal reaktif dan polisitemia,
meningkatkan kognisi, memperpanjang hidup, dan dapat menurunkan kejadian
rawat inap. Pemasangan oksigen transtracheal menghindari kotoran di sekitar

39

hidung dan mulut, menghindari "dead space" nasofaring, dan mencegah

ketidaknyamanan dan kekeringan terkait dengan penggunaan kanula hidung dan
masker. Perjalanan dengan tekanan tinggi memerlukan tambahan oksigen sekitar
0,5 L/ menit.
Pasien dengan PPOK memiliki insiden yang tinggi terhadap gangguan pernapasan
saat tidur yaituapneu obstruktif dan sentral dimana tekanan pernapasan positif
atau tekanan pernapasan bilevel dapat bermanfaat sebagai bantuan pernapasan,
pengistirahatan otot inspirasi pernapasan, dan kontra auto-positif tekanan akhir
ekspirasi untuk pasien PPOK hiperkapnia.

TABEL 141-3 Pengobatan umum

Golongan

Cara kerja

Efek utama

Efek samping

Bronkodilator

Antikolinergik
Simpatomimetik
Derifat metilxantin
Kombinasi
Ipratropium

Meredakan
bronkospasme
dengan relaksasi otot
polos bronkus
Meredakan
bronkospasme
dengan relaksasi dari
otot polos bronchial

Lihat kemasan obat

Tiotropium

Meredakan
bronkospasme

Antikolinergi
k

Sakit kepala, mulut

kering, pusing,
gangguan
gastrointestinal

Takikardi, palpitasi,
distress gastrointestinal,
gugup, mulut kering,
tremor.
Dari Referensi Physician Desk Edisi 61 Montvale NI Medical Economics 2007

Gangguan Ventilasi
Pengikat perut berguna untuk pasien tetraplegik dan paraplegik setinggi thorax
untuk meningkatkan peregangan diafragma dan kapasitas vital. Namun, kekuatan
otot inspirasi atau kapasitas vital pada pasien dengan gangguan ventilasi,
mobilisasi dinding dada dan paru-paru sangat penting untuk mempertahankan
pelebaran yang sesuai ketika volume paru-paru meningkat untuk mengeluarkan
batuk yang efektif.

40

Walaupun tekanan positif bilevel pernapasan dapat digunakan oleh pasien dengan
gangguan ventilasi, namun ini hanya sesuai untuk pasien yang tidak memiliki
kondisi bulbus yang mempersarafi otot yang berfungsi untuk menarik udara.
Ketika tekanan positif bilevel pernapasan dapat digunakan pada pasien ini, titrasi
polisomnografi menjadi tidak relevan. Tekanan positif bilevel pernapasan inspirasi
dan ekspirasi saat otot berelaksasi harus berada pada 18 sampai 20 cm H2O. Setiap
pasien dengan persarafan bulbar otot yang baik untuk menarik udara lebih
disarankan menggunakan ventilator volume-cycled daripada tekanan positif
bilevel pernapasan. Modifikasi dibuat untuk masker yang tidak nyaman dan
adanya kebocoran udara. Ventilator volume portabel dapat memberikan bantuan
pada otot inspirasi ketika dibutuhkan, seperti untuk pasien dengan obesitas
hipoventilasi.5
Konseling psikososial untuk gejala depresi, kecemasan, dan stress dapat
mengatasi gejala social dan menciptakan kemajuan yang baik pada pasien.
Tujuannya adalah untuk menghilangkan pengaruh gejala psikososial ini pada
penurunan siklus pernapasan.9
Insuflasi dan eksuflasi mekanik digunakan untuk membantu otot ekspirasi
pernapasam untuk meningkatkan arus batuk untuk mencegah pneumonia.
Digunakan 10 L/ detik dari aliran ekspirasi yang langsung menuju saluran napas
melalui saluran napas atas maupun trakeostomi (CoughAssist, JH Emerson Co.,
Cambridge, Mass). Bantuan mekanis batuk digunakan sebagai bantuan pada
tekanan perut dengan mengkombinasikan antara eksuflasi manual dan mekanik.17

Rehabilitasi
Sebuah program rawat jalan rehabilitasi paru menggabungkan intervensi fisik,
evaluasi peralatan pernapasan, dan rehabilitasi dengan pendekatan interdisipliner.
Tim interdisipliner dapat mencakup pasien, staf medis dan keperawatan, terapis
pernapasan, terapis fisik, terapis okupasi, terapis bicara, pekerja sosial, dan ahli
gizi. Selain itu, psikologi atau psikiatri, terapis rekreasi, dan rehabilitasi
vokasional yang dapat diintegrasikan sebagai bagian dari tim. Pelatihan aktivitas

41

untuk daya tahan, kekuatan dan aktivitas fungsi spesifik dijelaskan pada (Tabel
141-4). Kemajuan dimonitor dan modifikasi dibuat berdasarkan peningkatan
kapasitas aerobik pasien dengan latihan intensif. Jadwal pengubahan pola latihan
bergantung pada masing-masing pasien; tahap awal program dan masalah medis
akut dapat mendasari perubahan pada pola latihan. Komponen latihan meliputi
frekuensi, durasi, intensitas dan spesifisitas. Frekuensi latihan disarankan
sebanyak 3-5 kali seminggu. Pasien juga harus diajarkan tentang kebutuhan
pernapasan mereka.
Gangguan Oksigenasi
Latihan yang diberikan secara perlahan dapat memberi manfaat yang besar pada
pasien diantaranya adalah mengurangi dispneu dan laju pernapasan dan
meningkatkan toleransi terhadap latihan, meningkatkan konsumsi oksigen
maksimum, meningkatkan kemampuan berjalan 6-12 menit, meningkatkan
aktivitas sehari-hari, pekerjaan, efisiensi mekanik, dan pertukaran gas optimal. 23,27
Kecemasan dan depresi juga menurun secara signifikan, dan kognisi serta
kesejahteraan pasien meningkat.
Latihan dengan intensitas rendah dapat ditentukan atas dasar pemahaman objektif
atau subjektif. Pemahaman objektif melibatkan perhitungan konsumsi oksigen
maksimal atau detak jantung maksimal. Jika spirometri berbentuk open-circuit
dan metabolik cart tersedia, intensitas sasaran spesifik yang ditargetkan adalah
50% dari penyerapan oksigen maksimal. Parameter denyut jantung mungkin
paling berguna untuk pasien dengan kondisi jantung.

TABEL 141-4 Tipe latihan

Tipe latihan

Contoh

42

Latihan ventilasi otot

Inspiratory resistive exercise maximum

sustained ventilation, inspiratory resistive
loading, inspiratory threshold loading,
sustained hyperpnea

Latihan kekuatan

Upper extremity exercise pulleys, elastic

bands, supervised circuit training,
weightlifting with low resistance
Lower extremity exercise supervised
circuit training, weightlifting with low
resistance

Latihan ketahanan

Upper extremity exercise unsupported

upper extremity activities ranging from
activities of daily living to athletic
activities, supervised arm cycling low
impact aerobics, pool therapy
Lower extremity exercise incremental
treadmill program, supervised walking
cycling and stair climbing program low
impact aerobics, pool therapy.

Beberapa rumus yang digunakan. Salah satunya adalah intensitas latihan yang
diinginkan dikalikan dengan prediksi denyut jantung maksimum. Oleh karena itu,
jika intensitas latihan yang diinginkan didefinisikan sebagai 60% dari prediksi
denyut jantung maksimum (HR), maka:
Target HR = 0,60 x (HRmax = 220-umur)
Lainnya adalah formula Karvonen. Untuk target kisaran detak jantung 50%
menjadi 85%.
Cadangan

HR

[(HRmaks

HRistirahat)

0,50]

HRistirahat

= [(HRmaks - HRistirahat) x 0,85] + HRistirahat

Target awal bisa 50% (kisaran 50% sampai 80%) dari baik ukuran objektif atau
tingkat toleransi oleh pasien.

43

Ketika pemahaman objektif

tidak berlaku, seperti dalam kasus pasien yang

memakai obat kronotropik negatif (misalnya, bloker atau calcium channel

blockers) dan penerima transplantasi jantung, tindakan subjektif mungkin lebih
pada penyesuaian toleransi latihan. Selain itu, karena pasien sering dibatasi oleh
dispneu saat aktivitas, tindakan subjektif mungkin lebih disarankan.13
Tindakan subjektif dari toleransi latihan, seperti penilaian skala tenaga atau
penilaian dyspneu pada pasien, memungkinkan pasien untuk menentukan program
berdasarkan gejala mereka sendiri. Skala Borg dari 6 sampai 20 berbanding lurus
dengan detak jantung. Hal ini digambarkan dengan mengalikan jumlah skala yang
dipilih dengan 10 untuk mendapatkan perkiraan denyut jantung. Misalnya, ketika
pasien memilih nomor 10 pada skala untuk menggambarkan gejala, denyut
jantung

diperkirakan

dengan

persamaan

berikut:

10 x 10 = 100 (10)
Skala Borg asli menggunakan metode ini.13,28
Spesifisitas latihan ditentukan oleh tujuan yang diharapkan pada pasien untuk
menjalani kehidupan sehari-hari dan menjalani pekerjaan. Jadi mobilitas kegiatan
sehari hari pasien disesuaikan dengan program latihan yang diberikan. Program
latihan mobilitas dan daya tahan seperti berjalan, memanjat tangga, senam aerobic
yang low-impact, sepeda stasis dan terapi kolam renang dapat diberikan
tergantung dari tingkat mobilitas dan fungsional dasar tiap pasien. Untuk
mobilitas, pekerjaan, dan kegiatan rekreasi, alat-alat bantu untuk meningkatkan
kegiatan sehari-hari mungkin termasuk kursi roda, walker, atau tongkat. Latihan
kekuatan berfungsi untuk meningkatkan fungsi aktivitas sehari hari, mobilitas,
dan pekerjaan spesifik. Penggabungan untuk melatih ketahanan, kekuatan, dan
pekerjaan spesifik yaitu suatu teknik konservasi energi yang berguna pada
aktivitas sehari-hari. Peningkatan ketahanan pada latihan dapat tercapai secara
mandiri dilihat dari perubahan ketahanan otot ventilator.
Rangkuman dari program latihan dibuat oleh pasien dan pemberi terapi. Rencana
latihan disepakati oleh kedua belah pihak dan dapat secara fleksibel diganti,

44

disesuaikan dengan kondisi pasien. Dengan cara ini pasien diajak untuk ikut
bertanggung jawab terhadap kepatuhan dan kemandiriannya dalam menjalani
program latihan.
Latihan pernapasan digunakan untuk mencapai tujuan modifikasi pernapasan
untuk mengurangi kerja pernapasan dan meningkatkan mekanisme batuk.
Pengerutan bibir dalam pernapasan dan pernapasan diafragma dapat menurunkan
laju pernapasan, koordinasi pola pernapasan, dan cenderung mencegah bronkus
yang lebih kecil untuk kolaps. Pergantian udara dilakukan beberapa kali perjam.
Hal tersebut melibatkan inspirasi dalam yang ditahan selama 5 detik dengan
glottis tertutup. Udara berpindah ke daerah ventilasi paru yang lebih rendah dan
dapat mencegah mikroatelectasis. Pengkerutan bibir selama proses bernapas dapat
membantu proses relaksasi. Latihan relaksasi lainnya seperti latihan Jacobson dan
biofeedback, dapat digunakan untuk mengurangi ketegangan dan kecemasan.29,30
Untuk pasien hiperkapnia, periode jeda untuk relaksasi otot pernapasan dengan
latihan spesifik untuk otot pernapasan adalah dasar dari rehabilitasi paru.
Relaksasi dapat dicapai dengan penggunaan tekanan udara positif bilevel secara
nasal semalaman. Data mengenai peningkatan nilai pertukaran udara, peningkatan
kapasitas vital, penurunan kelelahan, dan peningkatan kesejahteraan telah banyak
dilaporkan sebagai hasil dari program tersebut.

TABEL 141-5 Rekomendasi perawatan hygiene paru 11,14,43

Inhaler
Bronkodilators
Steroid inhalasi
Inhibitor leukotrien
Mukolitik
Metode pengeluaran sekresi udara pernapasan
Suction oral, nasal, atau transtrakheal
Perkusi dada dan drainase postural
Pernapasan tekanan positif
Alat getar klirens mucus

45

Alat vibrasi mekanik untuk dinding dada

Pengobatan aerosol dalam ventilasi perkusif intrapulmoner
Penggunaan insuflasi-eksuflasi mekanik
Drainase autogenik
Bantuan batuk manual
Pengikat abdominal

Setelah dilakukan rehabilitasi akut, lalu dilanjutkan dengan pemantauan dan

perhatian khusus terhadap ketiadaan merokok, kebersihan bronkhial (Tabel 1415), latihan pernapasan, rekondisi fisik, terapi oksigen, dan mobilisasi pertukaran
udara terbukti dapat mengurangi kejadian rawat inap, waktu perawatan, dan biaya.
Manfaat rehabilitasi paru pada kinerja latihan dan kualitas hidup yang sangat
dirasakan oleh pasien yaitu sepanjang tahun pertama dan bertahan hingga 5 tahun
berikutnya. 26,27,35-37
Gangguan Ventilasi
Intervensi primer untuk pasien dengan kelemahan otot keseluruhan adalah dengan
menggunakan pengobatan otot pernapasan dan memfasilitasi habilitasi pada
ketidakmampuan daripada rehabilitasi. Puncak arus batuk yang lebih besar dari
160 L/menit merupakan kebutuhan minimal untuk pembersihan sekresi saluran
pernapasan dan mengindikasikan suatu kondisi aman untuk melepas tracheostomy
tube baik pasien merupakan ventilator dependen maupun tidak. Sembilan puluh
persen dari episode gagal napas akut dikarenakan oleh batuk yang tidak efektif
saat terjadi infeksi saluran pernapasan ringan; oleh karena itu ketika puncak arus
batuk dengan bantuan menurun kurang dari 270 L/menit, pasien dipantau dengan
oksimeter dan dilatih untuk menghirup udara yang diperlukan secara berkala
melalui mulut atau hidung dari sebuah resusitator manual (ambu bag) untuk
meningkatkan arus batuk.38 Mereka juga diajarkan bantuan batuk manual
(Sentakan abdominal untuk membuka glottis setelah insuflasi paru maksimal).
Mereka juga dikenalkan dengan insuflasi-eksuflasi mekanik (CoughAssist)

46

tersedia dari +35 ke +50 ke -35 ke -50 cm penurunan tekanan H2O, dengan
sentakan abdominal digunakan selama eksuflasi. Pasien harus dengan cepat
(kurang dari 2 jam) menggunakan ventilator volume portabel, CoughAssist, dan
bermacam mouthpiece dan nasal interface ketika mereka mengembangkan
metode latihan otot pernapasan-oksimetri untuk mencegah gagal napas, pasien
dan pemberi terapi disarankan untuk menggunakan pulse oxyhemoglobin
saturation (SpO2) berkelanjutan untuk memonitor tanda awal adanya infeksi
saluran pernapasan atas. Penurunan SpO2 kurang dari 95% menunjukkan keadaan
hipoventilasi atau adanya akumulasi mucus yang harus dibersihkanuntuk
mencegah atelecktasis, pneumonia, dan gagal napas. Pasien belajar untuk
menggunakan ventilasi noninvasif atau bantuan batuk manual atau mekanik untuk
mempertahankan ventilasi alveolar efektif dan klirens sekresi pernapasan untuk
menjaga kadar SpO2 sebesar 95% atau lebih dan sekaligus mencegah gagal napas.
Pasien juga diajarkan untuk menggunakan SpO2 untuk memonitor keadaan
mereka saat kelelahan, pernapasan pendek, atau sakit. Mereka disarankan untuk
menggunakan bantuan batuk manual atau mekanik saat diperlukan untuk
mempertahankan SpO2 normal setiap saat.
Saat menunjukkan gejala, umumnya terjadi penurunan SpO2 nokturnal dibawah
95%, dan pasien dianjurkan untuk menggunakan ventilasi tekanan positif
intermiten nasal nokturnal untuk pertama kali sebagai bantuan ventilasi paru
selama infeksi paru dan digunakan secara terus menerus tanpa rawat inap, pada
banyak kasus tanpa pengkurran kapasitas vital selama beberapa decade.35,36

Prosedur
Latihan dengan menggunakan nebulizers, hand-held inhalers, perkusi dada dan
drainase postural, dan perlengkapan pernapasan sangat penting selama program
rehabilitasi paru pada pasien rawat jalan. Inisiatif pasien dalam latihan ventilator
dan penggunaan alat CoughAssist sesuai waktu dan situasi klinis sangat penting
dalam proses rehabilitasi.

47

Pembedahan
Pembedahan untuk mengurangi volume paru dilakukan pada pasien dengan
emfisema berat dengan tujuan meningkatkan pertukaran gas, kapasitas latihan,
fungsi paru, dan kualitas hidup. Pasien yang diindikasikan untuk dilakukan
pembedahan yaitu pasien yang pernah menjalani operasi serupa, dan transplantasi
paru dan pasien post transplantasi paru dengan atau tanpa program rehabilitasi
program, tergantung pada tujuan rehabilitasi pasien dan stabilitas medis.37,38
Diantara pasien dengan disfungsi paru yang mengalami kekurangan gizi karena
intake oral yang kurang dapat diberikan rute alternatif pemberian makanan seperti
melalui gastrostomy tube perkutan.
Pasien dengan kerusakan otot pernapasan diajarkan untuk menggunakan bantuan
otot inspirator dan ekspirator (contohnya ventilasi mekanik noninvansif melalui
mulut dan nasal dan bantuan batuk secara mekanik) sebelum bedah sehingga
mereka bisa di ekstubasi untuk menggunakan alat bantu ini setelah bedah, bahkan
ketika mereka tidak dapat secara independen memventilasi paru mereka. 39
Tracheostomy dibutuhkan hanya ketika disfungsi otot-inervasi bulbar yang parah
sehingga membuat pasien teraspirasi saliva yang kemudian membuat SpO2 tidak
dapat dipertahankan pada kisaran 95% atau lebih tinggi. Umumnya, hal ini hanya
terjadi untuk pasien dengan sklerosis lateral amiotropik lanjut.40

KOMPLIKASI PENYAKIT
Komplikasi penyakit berperan penting dalam perencanaan rehabilitasi pasien
rawat jalan. Dalam perencanaan, sangat penting untuk mempertimbangkan
diagnosis spesifik pasien dan komplikasi yang mungkin timbul. Komplikasi dari
penyakit respirasi kronik tergantung pada efek progresivitas dari proses patologis
primer dan penuaan alami dari fungsi otot pernapasan dan jaringan paru.
Defisiensi nutrisi, masalah psikososial, dan factor komorbid juga berperan
penting.

48

Gangguan Oksigenasi
Pasien dengan gangguan oksigenasi primer karena penyakit paru atau saluran
napas sering mengalami eksaserbasi berulang dengan episode gagal napas akut.
Hal ini sering menyebabkan pasien dirawat dan diberikan manajemen invasif. Hal
ini biasanya disebabkan karena ketidakmampuan memobilisasi sekresi udara
pernapasan yang terjebak di perifer. Banyak sistem mobilisasi sekresi yang dapat
digunakan, namun tidak ada bukti yang jelas bahwa satu sistem bekerja lebih baik
daripada yang lain. Metode yang paling murah dan sederhana untuk memobilisasi
sekresi udara pernapasan, seperti penggunaan katup getar, masker pernapasan
tekanan positif dan vibrator dada, merupakan alat yang mungkin efektif sebanding
dengan chest vibrating yang mahal dan oscillating devices lainnya.41 Metode
tambahan pada mobilisasi sekresi pernapasan terapeutik yang dapat digunakan
mencakup perkusi dada dan drainase postural, huffing, dan siklus pernapasan
aktif. Yang terakhir merupakan teknik yang paling murah karena tidak ada
penggunaan alat bantu. Pasien hanya perlu bernapas perlahan dan dalam sampai
batas kapasitas fungsional residu; sehingga secara bertahap meningkatkan volume
tidal mendekati kapasitas fungsional residu dan begitu sampai, langsung bernapas
dengan dalam dan sekresi tiba-tiba. Strategi penting lainnya untuk pasien ini yaitu
dengan pemberian dan pemantauan kepatuhan terhadap antibiotic, bronkodilator,
oksigen, mukolitik, dan pengobatan lainnya.

Gangguan Ventilasi
Evaluasi proteksi jalur napas jangka panjang dengan trakeostomi merupakan
umum dilakukan. Namun, pasien tanpa kapasitas vital yang terukur atau
pergerakan otot rangka yang sadar lebih dari 50 tahun tidak membutuhkan
trakeostomi.42,43 Sangat jelas tidak dibutuhkan pada kegagalan otot inspirasi
maupun ekspirasi namun lebih kepada kegagalan otot persarafan bulbar sendiri.
Segera setelah aspirasi saliva menyebabkan batas bawah SpO2 dan tetap dibawah
95%, 90% pasien dengan trakeostomi akan meninggal dalam kurun waktu.40 Hal
ini hanya terjadi pada pasien dengan bulbar amiotropic lateral sklerosis yang

49

parah, pada anak dengan spinal muskular atropi tipe 1 tanpa perawatan rumah
yang tepat, pada pasien tertentu dengan facioscapulohumeral muskular distrophi,
dan sedikit lainnya. Pasien seperti itu sering memiliki bantuan aliran batuk
maksimal kurang dari 160 L/min dan tidak mampu melakukan air stacking
karena kegagalan penutupan glotis.45

KOMPLIKASI PENGOBATAN
Komplikasi pengobatan yang dapat terjadi akibat keracunan oksigen, barotraumas
akibat penggunaan ventilator, faktor komorbid seperti jantung konkomitan atau
penyakit atherosclerosis pembuluh darah perifer, dan pengobatan farmakologis.
Evaluasi rutin pada pengobatan pasien oleh klinisi sangatlah penting. Imobilitas
karena kelemahan otot atau penyakit akut dapat menyebabkan eksaserbasi paru
stasis dan menyebabkan thrombosis vena dalam, dekondisi jantung, ulserasi kulit,
dekalsifikasi tulang, dan kontraktur muskuloskeletal. Setiap kemajuan individual
dengan program mobilisasi, latihan, dan aktivitas sehari-hari dimonitor dan terapi
modifikasi diberikan sesuai dengan kebutuhan masing-masing pasien.
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