Asthma is a chronic lung disease and a very common respiratory condition. It is also known as reactive airway disease, which is often uncomfortable but manageable. Asthma can occur in all age groups, but it often begins in childhood. It is a disease characterized by repetitive shortness of breath and wheezing attacks, which vary in severity and frequency from person to person. In an individual, it can occur between hours and days. Asthma occurs due to inflammation and narrowing of the bronchial walls due to hyper-reactivity of their smooth muscles, thus leading to a series of spasmodic attacks of wheezing and shortness of breath.

Symptoms

-Wheezing
-Dry cough
-Chest tightness
-Sputum (fibrous, thick)
-Tiredness
-Itchy throat
-Runny nose
-Headache
-Difficulty breathing

There are about 300 million asthma patients all over the world. In recent years, the prevalence of asthma has been increasing (2%-30%) in young adults and children.Asthma is a disease that causes significant negative effects on the daily lives of patients and their families due to symptoms that can be seen day and night, hospital admissions, periods of absence from school and work, additional time devoted to treatment, and treatment costs.

In the report published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 2006, pulmonary rehabilitation (PR) was defined as follows:“PR is an evidence-based, multidisciplinary and comprehensive treatment for chronic respiratory patients who are symptomatic and have reduced activities of daily living attempt”.

Pulmonary rehabilitation is planned in addition to the individual treatment of the patient to reduce symptoms, keep respiratory functions at the optimum level, stabilize or improve systemic findings, reduce health costs, and increase patient participation in the treatment process.in order for pulmonary rehabilitation to be successful, it is important to identify the appropriate patient. Age, nutritional status, degree of respiratory disorder and patient compliance to treatment are the most important factors affecting pulmonary rahabilitation success.

Components of Pulmonary Rehabilitation in Asthma

1. The diagnostic process
   a. Measurement of respiratory functions
   b. Detection of bronchial hypersensitivity
   c. Evaluation of the presence of exercise-induced bronchoconstriction
   d. Physiology of respiratory work and maximum oxygen consumption
   e. Evaluation of compliance with treatment
   f. Assessment of the need for social and economic support
   g. Determination of educational needs
2. Optimal treatment of asthma
3. Education
   a. Asthma schools
   b. Individual training programs
   c. Written action plans
4. Exercise training
5. Climatotherapy
   a. High-altitude therapy
   b. Climate change

The Effects of Pulmonary Rehabilitation in Asthma

1-) The patients were included in a program that included breathing and exercise training and patient education.Other respiratory diseases and patients presenting with insufficient data were excluded from the study.In patients who completed the training, dyspnea, the number of exacerbations and lung function were analyzed and compared a year before and after the program.

The results show a benefit of pulmonary rehabilitation in patients with uncontrolled asthma. Pulmonary rehabilitation in these patients improves symptoms, reduces the number of exacerbations and can improve respiratory function.

2-) Researchers tried to investigate the effectiveness of pulmonary rehabilitation on functional exercise, dyspnea, and muscle fatigue in patients with severe asthma.

All participants underwent a 3-week multidisciplinary rehabilitation program with an 80% compliance to pulmonary rehabilitation.Enrollees were also needed to show their skills in performing and completing a 6-minute walking test (6MWT).Pulmonary rehabilitation includes endurance training, chest physiotherapy, breathing exercises, psychological support and training meetings.A 6-minute walking distance before and after pulmonary rehabilitation and a Borg scale for shortness of breath and muscles fatigue were recorded.

Analysis results showed that pulmonary rehabilitation significantly improved 6MWT, Borg dyspnea, and muscle fatigue.

The researchers concluded that this study provides evidence that, in a large sample of patients with severe asthma, a multidisciplinary pulmonary rehabilitation program improves exercise capacity and symptoms.(Zampogna E, Centis R, Negri S, et al. Effectiveness of pulmonary rehabilitation in severe asthma: a retrospective data analysis [published online August 13, 2019]. J Asthma. doi:10.1080/02770903.2019.1646271) 

CASE PRESENTATION

Clinical Story: A 50-year-old, 158 cm tall, 60 kg female patient is retired. The patient, who used to smoke passively as a child, lived in a city where coal stoves were used and the air pollution was seriously high. As a result of the increase in cough and shortness of breath, the patient applied to the department of chest diseases 13 years ago and was diagnosed with asthma. The patient with GINA stage 3 is followed up with regular drug therapy and 3-month controls. The patient, whose complaints increased despite drug treatment, was referred to the cardiopulmonary rehabilitation unit.

Clinical Information: The patient who has a positive skin test is allergic to house dust and pet hair. During seasonal changes, the patient was often receiving oxygen support in his home.The patient did not have the habit of regular exercise, and during the exacerbation there was a cough , wheezing breathing and shortness of breath , increased sputum.

Pre-Rehabilitation Assessment :

1-Resume: HT , Type 2 Diabetes , Osteopenia
2-Family History: His father had HT and his mother had asthma.
3-Cigarettes: 20 packs x years , left 10 years ago.

The Drugs She Used:

• Adalat crono = 2×1 = Antihypertensive
• Glyfor = 2×1 = Antidiabetic
• Symbicort = 2×1 = Long-acting corticosteroid
• Nexiual = 1×1 = Stomach protector
• Selectra = 1×1 = Antidepressant
• Vitamin D ampoule = 1×1 = Vitamin D support

Subjective Assessment:

• Resting dyspnea = no
• Exertional dyspnea = yes (severity 5) = climbing stairs, going uphill, walking fast
• Orthopnea = no
• Cough = no
• Sputum = none
• Hemoptysis = no
• Wheezing = yes
• Night sweats = no

Objective Assessment :

A) Vital signs

• Heart rate= 84
• Blood pressure = 115/78
• Respiratory frequency = 16
• SpO2= 97

B) Abnormal findings

• Both hemithorax were equal and less ventilated.
• Both hemithorax resonances were decreased.
• Breath sounds were decreased in both hemithorax.

C) Respiratory muscle strength measurement results

• MIP = 56
• MIP%= 69.6
• MEP=63
• MEP%= 42.3%

Test Interpretation = The patient’s MIP and MEP values are 80% lower than expected, so respiratory muscles are weak.

D) 6 minutes walking test:

• Heart rate = 84-125-106
• SpO2 = 97-96-98
• Blood pressure = 110/78 – 150/90 – 120/80
• Respiratory frequency = 16-28-20
• Dyspnea = 0-5-2
• Fatigue = 0-2-0
• Leg fatigue = 0-3-0
• Distance walked (m) = 507
• Distance walked (%) =78
  ( above findings at rest – after test – one minute recovery )

Test Interpretation = The patient did not use assistive devices and respiratory support during the test. The patient was not desaturated. The patient had no exercise tachypnea. There was severe level of dyspnea, mild level of fatigue, and moderate level of leg fatigue.

Short Term Goals =
1- To teach breathing control
2- Reducing shortness of breath
3- Increasing the ventilation of the lungs

Long Term Goals =
1- Risk factor education
2- Increasing peripheral muscle strength
3- Increasing respiratory muscle strength
4- Increasing exercise capacity
5- Reducing fatigue
6- Improving the quality of life

Cardiopulmonary Rehabilitation Program

1- Respiratory Muscle Training
Type = Inspiratory muscle strength training with the POWERbreathe Wellnes device
Severity = Level 3 , max insp. 60% of the pressure
Duration = 15 min
Frequency = 2 times / day, 7 days / week

2- Aerobic Exercise Training
Type = Bike
Training = 5 min warm up, 20 min load, 5 min cool down
Severity = 70% of max heart rate (119 beats / min)
Duration = 30 min
Frequency = 1 time/day, 5-7 days/week

3- Relaxation Exercises
Duration = 15 min
Frequency = 2 times/day, 7 days/week

4- Resistive Exercise Training
Type = Free weights attached to the wrists and ankles; knee extension (4kg), 90 degree shoulder abduction (3kg) and elbow flexion (3kg) in sitting position with feet dangling
Intensity = 8-10 reps
Frequency = 1 time/day, 3 days/week

Suggestions =
1- Not exercising at very cold and very hot times of the day.
2- Drinking warm water during aerobic exercise.
3- He was asked to stay away from cigarette smoke and allergens.

References=

1-Güçlü Boşnak Meral, Cardiopulmonary Rehabilitation with Cases (Hipocrates Bookstore 2017)

2-Erk Müzeyyen, Ergün Pınar, Pulmonary Rehabilitation (Toraks Books 2009)