Pulmonary Rehabilitation in Chronic (Obstructive) Pulmonary Disease

Pulmonary Rehabilitation
in Chronic (Obstructive) Pulmonary Disease
What you have to do before you can say
you’ve done everything
Sanjay Kalra MD, FRCP
Director, Outpatient Pulmonary Rehabilitation
Mayo Clinic
Rochester, MN, USA
Consequences of Chronic Respiratory Disease
Peripheral muscle dysfunction
Deconditioning, steroid myopathy, critical illness
neuropathy, malnutrition, decreased lean body
mass, fatigue, effects of hypoxemia, acid-base
disturbance, electrolyte abnormalities
Respiratory muscle dysfunction
Mechanical disadvantage secondary to
hyperinflation, malnutrition, diaphragmatic
fatigue, steroid myopathy, electrolyte abnormalities
Nutritional abnormality
Obesity, cachexia, decreased lean body mass
Cardiac impairment
Deconditioning, cor pulmonale
Skeletal disease
Osteoporosis, kyphoscoliosis
Sensory deficits
Impaired vision, hearing, etc
Medication effects
e.g.steroids, diuretics, antibiotics
Psychosocial
Anxiety, depression, guilt, panic, dependency,
cognitive deficit, sleep disturbance, sexual dysfunction
Pulmonary Rehabilitation
Definition
A multi-disciplinary program of care for
patients with chronic respiratory impairment
that is individually tailored and designed to
optimize physical and social performance and
autonomy
Pulmonary Rehabilitation, AJRCCM 1999
Am J Resp Crit Care Med 173:1390–1413, 2006
Pulmonary Rehabilitation
Definition
Pulmonary rehabilitation is an evidence-based,
multidisciplinary, and comprehensive intervention for
patients with chronic respiratory diseases who are
symptomatic and often have decreased daily life activities.
Integrated into the individualized treatment of the patient,
pulmonary rehabilitation is designed to reduce symptoms,
optimize functional status, increase participation, and
reduce healthcare costs through stabilizing or reversing
systemic manifestations of the disease
AJRCCM 2006
The impressive rise in interest in pulmonary
rehabilitation is likely related to both a
substantial increase in the number of patients
being referred as well as the establishment of
its scientific basis by the use of well-designed
clinical trials that use valid, reproducible, and
interpretable outcome measures
AJRCCM 2006
An Official ATS/ERS Statement: Key Concepts and
Advances in Pulmonary Rehabilitation
Pulmonary rehabilitation is a comprehensive
intervention based on a thorough patient assessment
followed by patient-tailored therapies which include, but
are not limited to, exercise training, education and
behavior change, designed to improve the physical and
psychological condition of people with chronic
respiratory disease and to promote the long-term
adherence to health-enhancing behaviors.
Am J Respir Crit Care Med, 188:e13–e64, 2013
Overview of Pulmonary Rehabilitation
Objectives


Control and alleviate the symptoms
and pathophysiological impairments
of respiratory disease
Teach the patient how to achieve
optimal capability in carrying out
acitivities of daily living
American Thoracic Society 1981
Pulmonary Rehabilitation
Measurement Tools
• PFTs
• Exercise capacity
Cardiopulmonary exercise tests
Timed walk distance tests
(6 minute walk, Incremental shuttle walk)
• Dyspnea scores
• Quality of Life measures
Pulmonary Rehabilitation
Components of a Program
• Exercise Training
Endurance training - upper/lower extremity
Strength training
Respiratory muscle training
Issues:
High vs Low intensity exercise
Training reversibility
Long-term adherence
• Education
Pulmonary Rehabilitation
Guidelines for Endurance Exercise Training in COPD

Intensity
Moderate-severe disease (FEV 1 <1.2 L), ventilatory limited,
not anerobic on initial symptom limited exercise testing
Symptom limited training/typically 90-100% of baseline maximum workload
Start low and build up
Mild-moderate disease (FEV 1 >1.2 L), anerobic on higher
exercise levels at initial testing
Work level at initial anerobic threshold/typically 70-90% of baseline
maximum workload

Frequency
Daily home exercise (start with supervised sessions 1-2/wk x 6-8 wks)

Duration
15-30 min continuous (or interval) activity
Ries, Clin Chest Med 1994
You have a serious illness of an undisclosed nature
Pulmonary Rehabilitation
Common Educational Topics
•
•
•
•
•
Anatomy/Physiology of the lung
•
•
•
•
•
•
•
•
•
•
•
•
•
Medications
Pathophysiology of lung disease
Airway management
Breathing training strategies
Energy conservation and work simplification
techniques
Self-management skills
Benefits of exercise/safety guidelines
Oxygen therapy
Environmental irritant avoidance
Respiratory and chest therapy techniques
Symptom management
Psychological factors - coping, anxiety, panic control
Stress management
End of life planning
Smoking cessation
Travel/leisure/sexuality
Nutrition
Pulmonary Rehabilitation
Does it work?
Ries et al Ann Intern Med 1995;122:823-832
Treadmill Endurance Exercise
* p<0.05 for within-group
change from baseline
Ries et al Ann Intern Med 1995;122:823-832
Maximum Treadmill Workload
Ries et al Ann Intern Med 1995;122:823-832
Self-reported Shortness of Breath
Ries et al Ann Intern Med 1995;122:823-832
Survival following Rehabilitation
Ries et al Ann Intern Med 1995;122:823-832
Rehabilitation and Exercise Capacity
A Metanalysis
Lacasse et al, Lancet 1996
Exercise training and Dyspnea
Dyspnea (Borg Scale)
6
Bronchodilators
Severe
5
Oxygen
Somewhat severe
4
Moderate
3
Slight
2
Very slight
1
None
Exercise training
0
0
2
4
6
8
10
12
14
16
Endurance Exercise Time (min)
ATS Consensus Statement, 1999
Pulmonary Rehabilitation
Respiratory Muscle Training
•
Inspiratory and Expiratory muscle training
Inspiratory Muscle Training
6 minute walk
Inspiratory Muscle Training
Control
Weiner et al ERJ 2004
Inspiratory Muscle Training
Dyspnea Score
Control
Inspiratory Muscle Training
Weiner et al ERJ 2004
You should have called me sooner!
Wedzicha et al, ERJ 1998
Wedzicha et al, ERJ 1998
Age and Ageing Advance Access published June 19, 2008
Age and Ageing
doi:10.1093/ageing/afn126
Ó The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Age does not hamper the response to
pulmonary rehabilitation of COPD patients
FRANCESCO DI MEO 1, CLAUDIO PEDONE2, SERGIO LUBICH1, CARLO PIZZOLI1, MARCO TRABALLESI1,
RAFFAELE ANTONELLI INCALZI2
1
Fondazione Santa Lucia, Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
Geriatria, Universit à Campus Biomedico, Roma, Italy
2Cattedra di
Address correspondence to: Claudio Pedone. Email: [email protected]
Abstract
Background: pulmonary rehabilitation (PR) improves health status and exercise tolerance, but not respiratory function in
patients with chronic obstructive pulmonary disease (COPD). Our objective was to identify predictors of improvement in
the 6-min walked distance (6 WD) in elderly COPD patients after PR.
Methods:this was a prospective observational study performed in an ambulatory rehabilitation setting. We enrolled 74 patients
aged 65–83 years (mean: 74.2, SD: 4.4) with stable COPD in GOLD stage 3–4. About half (45.6%) of them had a basal O2
Pulmonary Rehabilitation
in
Diseases other than COPD
Common Indications for Referral for
Pulmonary Rehabilitation
Respiratory disease resulting in:



Anxiety engaging in activities
Breathlessness with activities
Limitation with:
Social activites
Leisure activities
Indoor and/or outdoor chores
Basic or instrumental activities of daily living

Loss of independence
Pulmonary Rehabilitation
Program Setting
Inpatient
Outpatient
Homebased
Advantages
Disadvantages
Close medical monitoring/nursing care
Cost/insurance reimbursement
Sickest patients with greatest deficit
can participate
Separation from family
Widely available
Least expensive
Efficient resource utilisation
Least intrusive to family
Transportation issues
Patient convenience
Cost/insurance reimbursement
Real life activities
Lack of group support
No opportunity to observe home
activities
Lack of full spectrum of
multidisciplinary program
Holland et al, J Telemed and Telecare 2013
Telerehabilitation for people with COPD: Feasibility of a
simple, real-time model of supervised exercise training
N=8
Pulmonary Rehabilitation
Unanswered questions and future directions
•
•
•
•
•
•
Effects on Health Care Cost/Survival ?
Essential components of a program ?
Intensity, duration and type of exercise ?
Pharmacotherapy? Neuromuscular stimulation?
Respiratory muscle rest ?
Can exercise prescription adherence be improved
?
• Outcomes - Exercise vs Quality of life ?
• Factors predicting improvement ?