Rehabilitation of the Disabled Patient with Chronic Bronchitis and Pulmonary Emphysema

Abstract

CHRONIC, obstructive pulmonary disease is the most frequent cause of physical disability associated with pulmonary disorders. The pathogenesis of disability arising from pulmonary disease can be summarized as follows: either pulmonary ventilatory or circulatory insufficiency may be responsible for exertional dyspnea which, in turn, causes fear and inactivity. Fear, itself, tends to promote further inactivity. Inactivity promotes diminished muscle tone, decreased muscle efficiency, easy fatigability, and progressive physical debility. All of these in turn lead again to more inactivity and exertional dyspnea. Thus a vicious cycle of events is established which eventually leads to even more serious difficulties, such as venostasis with the threat of phlebothrombosis and pulmonary embolization, increased bone resorption which may result in fractures and deformity, and decreased cardiac function. Having recognized the existence of debility, then the need for rehabilitation becomes apparent. The execution of a complete physiological treatment program,' prior to the active physical rehabilitation, must be considered as a prime requisite to a successful rehabilitation program. It is first necessary to improve ventilatory function to an optimum. The initial step consists of removal of all irritants, especially cigarette smoking and other pollutants. The existence of bronchial infection must be identified and treated with appropriate antibiotics. Bronchial edema and bronchospasm can be treated with oral and aerosol bronchodilator agents. When the cause of the obstruction is retained inflammatory exudate or secretions, as is so often the case, then bronchial hygiene becomes essential. The latter is probably the single most neglected aspect of treatment. The methods for achieving effective bronchial hygiene, which have been presented elsewhere,2-5 deserve much more comment than space will permit. Intensive use of saline or detergent aerosols (particularly heated aerosols), deep breathing, rotary postural drainage, with chest clapping or vibration and occasionally potassium iodide as an expectorant, will be necessary. Finally, in those situations where the inflammatory reaction is resistant to protracted and diligent therapy as outlined, the administration of steroids, either orally or by aerosol, may be indicated in order to improve bronchial integrity to an optimum. Patient edqgatiozm is one of the most important components of rehabilitation programs. The patient must be informed concerning the mechanical nature of his disease and the factors responsible for his breathing difficulty. In ventilatory obstructive disease, the work of breathing is done largely in overcoming the resistance to airflow.6 Thus it becomes essential that the patient maintain the slowest feasible respiratory pattern. In addition, because of the tendency for the airways to collapse during rapid ex-