Pulmonary Rehabilitation In COPD Dr. Alastair Jackson September 2004.

Pulmonary Rehabilitation Pulmonary Rehabilitation In COPDIn COPD

Dr. Alastair JacksonDr. Alastair Jackson

September 2004September 2004

09/200409/2004 Dr. Alastair JacksonDr. Alastair Jackson

What is Pulmonary Rehabilitation?What is Pulmonary Rehabilitation?

“…“…a multidisciplinary programme of care for a multidisciplinary programme of care for patients with chronic respiratory patients with chronic respiratory

impairment that is individually tailored and impairment that is individually tailored and designed to optimise each patient’s designed to optimise each patient’s physical and social performance and physical and social performance and

autonomy.” (NICE)autonomy.” (NICE)


Why is it important?Why is it important?

• COPD causes 30,000 deaths per year and leads to extensive COPD causes 30,000 deaths per year and leads to extensive morbidity. It incurs massive costs in relation to hospital morbidity. It incurs massive costs in relation to hospital admissions, incurring nearly 6 times as many bed days of admissions, incurring nearly 6 times as many bed days of inpatient care as asthma.inpatient care as asthma.

• Interventions which improve quality of life and level of functioning Interventions which improve quality of life and level of functioning are important since few interventions except smoking cessation are important since few interventions except smoking cessation affect disease progression.affect disease progression.


Benefits of Pulmonary RehabilitationBenefits of Pulmonary Rehabilitation

• Break out of the “emotional straightjacket”Break out of the “emotional straightjacket”

NICE:NICE:

• Improved exercise capacity (A)Improved exercise capacity (A)

• Improved health-related quality of life (A)Improved health-related quality of life (A)

• Reduced hospitalisations and length of stay (A)Reduced hospitalisations and length of stay (A)

• Reduced anxiety and depression associated with COPD (A)Reduced anxiety and depression associated with COPD (A)

• ? Increased survival (ACCP)? Increased survival (ACCP)

• Benefits probably extend well beyond the period of rehab, Benefits probably extend well beyond the period of rehab, especially if exercise training is maintained at home. (GOLD)especially if exercise training is maintained at home. (GOLD)


In what settings?In what settings?

• Effective in inpatient, outpatient and community settings and Effective in inpatient, outpatient and community settings and possibly at home.possibly at home.

• Should be held at times that suit patients in buildings that are Should be held at times that suit patients in buildings that are easy to access with appropriate access for those with disabilities.easy to access with appropriate access for those with disabilities.


Who is it for?Who is it for?

• All disease severities (but may not benefit if unable to walk)All disease severities (but may not benefit if unable to walk)

• ……where SYMPTOMS AND DISABILITY are present (usually MRC grade 3)where SYMPTOMS AND DISABILITY are present (usually MRC grade 3)

• No justification for selection on basis of age, impairment, disability, No justification for selection on basis of age, impairment, disability, smoking status or oxygen usesmoking status or oxygen use

• Enrolment on a smoking cessation programme a pre-requisite for Enrolment on a smoking cessation programme a pre-requisite for inclusion?inclusion?

• Continuing smokers may be less likely to completeContinuing smokers may be less likely to complete

• Contra-indicated if recent MI/ unstable anginaContra-indicated if recent MI/ unstable angina


Course Content and DurationCourse Content and Duration

• The longer the better but usually 6-12 weeks (NICE). Minimum The longer the better but usually 6-12 weeks (NICE). Minimum effective length 8 weeks (GOLD)effective length 8 weeks (GOLD)

• Diagnostic assessmentDiagnostic assessment

• Baseline and outcome assessments: exercise capacity (shuttle Baseline and outcome assessments: exercise capacity (shuttle walk), disability/health status (questionnaire)walk), disability/health status (questionnaire)

• Interventions : exercise training, educational, psychological, Interventions : exercise training, educational, psychological, nutritionalnutritional


Exercise Training: Frequency, Intensity and DurationExercise Training: Frequency, Intensity and Duration

• Daily to weekly (x3/week)Daily to weekly (x3/week)

• 10-45 mins (? < 20 mins insufficient to elicit a training effect)10-45 mins (? < 20 mins insufficient to elicit a training effect)

• 50% intensity (50% peak oxygen consumption) upto maximum 50% intensity (50% peak oxygen consumption) upto maximum

• Optimum duration not determined but usually 4-10 weeks (longer Optimum duration not determined but usually 4-10 weeks (longer courses show greater effects)courses show greater effects)


Exercise Training: Which muscle groups?Exercise Training: Which muscle groups?

• Lower limb training improves exercise tolerance though no effect on Lower limb training improves exercise tolerance though no effect on measured lung functionmeasured lung function

• DOESN’T HAVE TO BE HI TECH- corridor training commonDOESN’T HAVE TO BE HI TECH- corridor training common

• Upper limb training improves arm strength and reduces ventilatory Upper limb training improves arm strength and reduces ventilatory demanddemand

• Respiratory muscle training may influence endurance and dyspnoea Respiratory muscle training may influence endurance and dyspnoea but evidence is conflictingbut evidence is conflicting


Psychological componentsPsychological components

• COPD is associated with anxiety and depressive symptoms which COPD is associated with anxiety and depressive symptoms which may interfere with activities of daily living (ADL’s)may interfere with activities of daily living (ADL’s)

• Evidence lacking for short term psychological interventions as a Evidence lacking for short term psychological interventions as a single therapeutic modality but longer term interventions may be single therapeutic modality but longer term interventions may be beneficialbeneficial

• Expert opinion supports the use of educational and psychological Expert opinion supports the use of educational and psychological interventions in pulmonary rehab programmesinterventions in pulmonary rehab programmes

• Typical goals: address depression/anxiety, teach relaxation skills, Typical goals: address depression/anxiety, teach relaxation skills, discuss relevant issues such as sexuality, family and work discuss relevant issues such as sexuality, family and work relationshipsrelationships

• The most positive evidence relates to adherence intervention and The most positive evidence relates to adherence intervention and cognitive modificationcognitive modification


EducationEducation

• Usually in group classes. Evidence lacking for educational Usually in group classes. Evidence lacking for educational interventions in isolation though benefits as part of a interventions in isolation though benefits as part of a multidisciplinary approach widely acceptedmultidisciplinary approach widely accepted

• Wide variety of topics: A+P, pathology, breathing retraining, Wide variety of topics: A+P, pathology, breathing retraining, nutrition, medication regimens and mechanisms, importance of nutrition, medication regimens and mechanisms, importance of exercise, managing dyspnoea, self-management, travel advice, exercise, managing dyspnoea, self-management, travel advice, safe oxygen use, advance directives and end of life decisions safe oxygen use, advance directives and end of life decisions where appropriatewhere appropriate


Nutritional counsellingNutritional counselling

• Both overweight and underweight can be a problemBoth overweight and underweight can be a problem

• 25% of patients with moderate to severe COPD show a reduction 25% of patients with moderate to severe COPD show a reduction in BMI which is an independent risk factor for mortality in COPDin BMI which is an independent risk factor for mortality in COPD

• Reasons for difficulty eating should be explored: poor dentition, Reasons for difficulty eating should be explored: poor dentition, dyspnoea whilst eatingdyspnoea whilst eating

• Advise frequent small mealsAdvise frequent small meals


CostsCosts

• Costs of rehab per QALY gained estimated at £2,000-£8,000Costs of rehab per QALY gained estimated at £2,000-£8,000

• Overall, pulmonary rehab is probably cost saving (probability 0.64) and Overall, pulmonary rehab is probably cost saving (probability 0.64) and improves quality of lifeimproves quality of life


ReferencesReferences

• NICE: National clinical guidelines on management of COPD in adults in NICE: National clinical guidelines on management of COPD in adults in primary and secondary careprimary and secondary care

• GOLD: Global strategy for the diagnosis, management and prevention GOLD: Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary diseaseof chronic obstructive pulmonary disease

• Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based Guidelines. Chest/ 112 / 5 / November 1997Guidelines. Chest/ 112 / 5 / November 1997

• Y Lacasse, L Brosseau, S Milne, S Martin, E Wong, GH Guyatt, RS Y Lacasse, L Brosseau, S Milne, S Martin, E Wong, GH Guyatt, RS Goldstein, White J, Pulmonary rehabilitation for chronic obstructive Goldstein, White J, Pulmonary rehabilitation for chronic obstructive pulmonary disease (Cochrane review). In: The Cochrane Library, issue pulmonary disease (Cochrane review). In: The Cochrane Library, issue 3, 2004.3, 2004.

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Pulmonary Rehabilitation In COPD Dr. Alastair Jackson September 2004.

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