Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization Prof. Dr. Müzeyyen...

Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization

Prof. Dr. Müzeyyen Erk

Cerrahpaşa Medical Faculty

Chest Disease Dept.

Plan

Chronic Respiratory Disease Definition Factors Contributing to Exercise Intolerance in CRD

Pulmonary Rehabilitation Definition Patient Assessment and Selection Program Setting

Chronic diseases Definition

“All impairments or deviations from normal which have one of more of the following characteristics: they are permanent they leave residual disability they are caused by non-reversible pathological

alterations they require special training of the patient for

rehabilitation they may be expected to require a long period of

supervision, observation or care

Factors limiting exercise

CENTRAL PERIPHERAL

• LUNG DYNAMIC HYPERINFLATION

• REDUCED VENTILATORY RESERVE

• COST OF BREATHING

• MUSCLE ATROPHY,

CAPILLAR DENSITY

• POOR NUTRITIONAL STATE

• POOR BIOENERGETICS

• METABOLIC ACIDOSIS

Daily physical activity pattern in COPD

Walking Standing Sitting Lying Others

6

11 41

27

42

52 12

0% 20% 40% 60% 80% 100%

Healthyelderly(n=25)

COPDpatients(n=50)

4

Pitta et al. Am J Respir Crit Care Med. 2005;171:972-977

Air trapping

Hyperinflation

Airflow obstruction

Poor health-related quality of life

Activity limitationDyspnea

PatientCenteredOutcomes

Anxiety

Tachypnea Ventilatory requirement

Deconditioning

COPDCOPD

Hypoxemia Exacerbations

Cooper CB. Am J Med 2006;

119(10A): S21-S31.

Chronic respiratory

disease

Pulmonary phsiological abnormality

IC, exercise endurance and dyspnea

InspiratoryCapacity

Exercise EnduranceExertionalDyspnea

r=-0.50P<0.001

r=-0.61P<0.001

r=0.52P<0.001

O’Donnell et al. Eur Respir J. 2004;23:832–840

Dynamic hyperinflation during exercise in COPD

O’Donnell D, Chest 2000

Schols et al. ARRD 1993; 147: 1151-6

0

10

20

30

40

50

11%

27%

41%

46%

Mild COPD

(FEV1 > 50 %)

(n=37)

Moderate COPD

(FEV1 35-50 %)

(n=56)

Severe COPD

(FEV1 < 35%)

(n=112)

Resp. Failure

(PaO 2 < 55 Torr)

(n=48)

% p

ati

en

ts w

ith

lo

w b

od

y w

eig

ht

(< 9

0%

id

ea

l B

W)

Body composition

Peripheral muscle weakness in COPD

Bernard S et al. AJRCCM 1998; 158: 629-34

Richardson RS Richardson RS et al. AJRCCM et al. AJRCCM 2004; 169: 89-962004; 169: 89-96

(Vastus Lateralis)

Fiber type changes Atrophy Apoptosis

Structural changes in skeletal muscle in COPD

FEV1 %32

PaO2 87

Exercise capacity as a predictor of mortalityP

ropo

rtio

n s

urv

ivin

g

Months of follow-up

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0 12 24 36 48 60

III

III

IV

I: Peak VO2: >995 mL/min (n=37)

II: Peak VO2: 793 -995 mL/min (n=38)

III: Peak VO2: 654 - 792 mL/min (n=38)

IV: Peak VO2: <654 mL/min (n=37)

Oga T, et al. Am J Respir Crit Care Med 2003;167:544-549

Interventions aimed at improving exercise capacity (i.e. quality of life)

Oxygen

Heliox

Rehabilitation

Bronchodilators

LVRS

Plan

Chronic Respiratory Disease Definition Factors Contributing to Exercise Intolerance in CRD

Pulmonary Rehabilitation History Definition Patient Assessment and Selection Program Setting

Pulmonary rehabilitation 1970s: The first controlled trials on PR 1980s: Initial skepticism Ideal candidates: Despite optimal medical

treatment, significant abnormalities in their function and their participation in everyday life, leading to impaired HRQoL

GOLD: PR should be considered in patients with an FEV1 below 80%

Most national and international guidelines consider PR an important treatment option

NETT: Strong encouragement for the implementation of PR programs for patients with COPD.

ERS-ATS statement 2006

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 reduce health care costs through stabilizing or

reversing systemic manifestations of the disease.

Definition

Pulmonary rehabilitation

Integrated into the lifelong management of patients with chronic respiratory disease

Involves a dynamic, active collaboration among the patient, family, and health care providers

ERS-ATS statement 2006

Chronic respiratory conditions that benefit from PR program

COPD Asthma Chest wall disease Cystic fibrosis Interstitial lung disease; post-ARDS pulmonary fibrosis Lung cancer Neuromuscular diseases such as post–polio syndrome

Exercise program may not be appropriate for advanced disease Flexibility training Optimization of ventilator assistance re:

Perioperative states (e.g., thoracic, abominal surgery) Pre- and post–lung transplantation, LVRS

Pulmonary vascular disease

Indications to pulmonary rehabilitations

Symptomatic impairment attributable to pulmonary disability

Failure of standard medical regimen to achieve adequate symptomatic relief

Motivated, adherent patient

Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

Contrindications to pulmonary rehabilitation Lack of motivation Nonadherence Inadequate financial resources Severe cognitive dysfunction or

psychiatric illness Unstable comorbidity (unstable

angina, uncompensated congestive heart failure)

Severe exercise-induced hypoxemia, not correctable with O2 supplementation

Inability to exercise due to severe lung or other disease (arthritis, stroke)

Cigarette smoking*


Setting for pulmpnary rehabilitationPulmonary rehabilitation is administered: inpatient outpatient home settings combination of these

inpatient rehabilitation:In the United States: To be disabled to travel to and from an outpatient program Focus of these programs is more often on optimizing medical or

ventilator regimens than on the exercise componentsIn Europe: Ambulatory patients may be admitted to an inpatient program to

undergo intensive therapy To avoid the inconvenience of daily travel

MULTIDISCIPLINARY TEAM PARTICIPATING ON A PULMONARY REHABILITATION TEAM

Physicians Pulmonologist Physiatrist

Therapists Physical Occupational Respiratory

Nurse or exercise physiologist

Nutritionist Social worker Psychologist


TEAM

Keys for successful pulmonary rehabilitation ?

Patient selection Program components

PATIENT SELECTION

ANY STABLE PATIENT WITH

DISABLING SYMPTOMS

(ACCP/AACVPR) ?

PULMONARY FUNCTION ? AGE ? CO-MORBIDITY ? SMOKING ? PSYCHOSOCIAL CONDITIONS

? MUSCLE WEAKNESS ?

MODIFICATION

Components of a rehabilitation programme

Patient education Psychosocial support Chest physiotherapy Exercise training Muscle training Nutritional support


Educa-

tion

Psyco-social

support

General exercise training

Selected muscle training

Chest physio-therapy

Occupa- tional

therapy

Nutritional inter-

vention

COPD +++ ++ +++ ++ + ++ +

Asthma ++ ++ +++ ++

CF & bronchiect. ++ ++ +++(*) ++(*) +++ + ++

Chest wall disor. + + +

Neuromusc. dis + ++ +

Respir sleep dis + ++ + + +

Interst lung dis

Pre-post surgery ++ ++ +++ ++ +++ ++

Tracheostom pat ++ ++ + + + +

Main components of PR programmes Donner CF, Decramer M. Pulmonary Rehabilitation ERJ Monograph, 2000: 13:132-142

(+): No evidence, (++): Few evidences, (+++): Good evidence, (*): Before transplantation

Topics often covered during group education sessions

What’s wrong in common lung diseases Breathing medications Oxygen therapy Energy conservation techniques Relaxation techniques Breathing techniques

Pursed lip breathing Diaphragmatic breathing

Nutrition What to do in emergencies Traveling with lung disease End-of-life issues


Significant benefits of pulmonary rehabilitation

Established by multiple randomized controlled trials (Level A evidence)1. Improved functional capacity (6-min walk or Shuttle

Walk Test)

2. Reduced dyspnea*

3. Improved health-specific quality of life*

Observed in some randomized controlled trials (Level B evidence)1. Reduced need for hospitalization*

* Only in patients with COPD with severe airway obstr.


Improves exercise capacity A

Reduces intensity of breathlessness A

Improves HRQoL A

Reduces hospitalizations A

Reduces anxiety and depression A

Improves arm function B

Improves survival B

Respir. muscle tra. (+ general exer) C

Psychosocial intervention C

GOLD Exc. Summ. 2008

Benefits of Pulmonary Rehabilitation in COPD

The vicious circle

Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.

Chronic Pulmonary Disease

Physical Deconditioning

Physical Deconditioning

Physical Reconditioning

Physical Reconditioning

Decreased Exercise Capacity

Decreased Exercise Capacity

Increased Exercise Capacity

Increased Exercise Capacity

Increased Breathlessness

Increased Breathlessness

Decreased Breathlessness

Decreased Breathlessness

Immobility Pulmonary Rehabilitation

Increased VE Requirements

Increased VE Requirements

Decreased VE RequirementsDecreased VE Requirements

Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization Prof. Dr. Müzeyyen...

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