Chuck Kitchen, MA, FAACVPRChuck.kitchen@gmail.com

OBSTRUCTIVE DISEASESCOPD-Chronic airway obstructionEmphysema-Hyperinflation of the

lungs, can’t get bad air outChronic Bronchitis-Chronic sputum

production and coughingAsthma-increased airway reactivity

leading to narrowing of airways

PR only covered for Moderate, Severe, Very Severe COPD

GOLD classification

Chronic lower respiratory diseases ICD-10: J40-J47

Obstructive Lung Disease: Persistent asthma: 493 Bronchitis: 491 Bronchiectasis: 494 COPD: 496 Cystic fibrosis: 277.03 Bronchiolitis obliterans: 491.8 Emphysema: 492

AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th

ed. 2010, Champaign, IL: Human Kinetics Publishers.

Restrictive Lung Diseases: Interstitial diseases: 518.89 (J84.1-9)

▪ Idiopathic interstitial fibrosis: 516.31 (J84.10-J84.111-117)▪ Other interstitial pulmonary disease with fibrosis: J84.17▪ Occupational or environmental lung disease:

518.89(Z57.31)▪ Sarcoidosis: 517.8 (Lung involvement) (D86.0, 86.2)

Chest wall diseases:▪ Kyphoscoliosis: 737.3 (M41.8)▪ Ankylosing spondylitis: 720.0 (M45.3-45.5)

AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th

ed. 2010, Champaign, IL: Human Kinetics Publishers.

Restrictive Lung Diseases, Continued: Neuromuscular diseases:

▪ Parkinson’s: 332 (G20)▪ Postpolio syndrome: 138 (G14)▪ Amyotrophic lateral sclerosis: 335.2

(G12.21)▪ Diaphragmatic dysfunction: 518.89 (J98.6)▪ Multiple sclerosis: 340 (G35)▪ Post-tuberculosis syndrome: 518.89 (A-15)

AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th

ed. 2010, Champaign, IL: Human Kinetics Publishers.

Obesity-related Respiratory Disorders: Obesity hypoventilation syndrome: 278.03 Obstructive sleep apnea: 327.23

Other Lung Disorders: Lung cancer: 162 Pulmonary hypertension: 416-417.8 ( Post-lung transplant: V42.6

AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th

ed. 2010, Champaign, IL: Human Kinetics Publishers.

Pulmonary Rehabilitation must be the ONLY service billed using G0424

Sessions limited to a maximum of two 1-hour sessions per day for up to 36 sessions

Contractors may approve up to an additional 36 sessions when medically necessary. Providing access of up to 72 sessions of PR,

when appropriate Does not specify a duration by which sessions

must be completed; allowing the maximum allowable number of 72 over a longer period of time

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42.CFR 410.47

G0424: Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session Revenue Code: 0948 Session duration:

▪ One session = > 31 minutes▪ Two sessions = > 91 minutes, with the first

session = 60 minutes and second session = 31 minutes

Do NOT bill any other codes for the COPD patient

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Interstitial Lung Diseases Environmental-asbestos, dust, coal, etc Drugs or chemotherapy Collagen diseases (scleroderma, lupus,

etc) Pulmonary fibrosis

Vascular Lung Diseases Pulmonary Hypertension

3-5 days per week Walking (preferred) and cycle 20-60 min RPE 5-6 (Moderate) Or 7-8 (Vigorous) for

Mild COPD RPE 3-5 for Moderate to Severe COPD No upper extremity recommended Does not use GOLD criteria Strength Training-2-4 sets, 2-3

days/week

0 Nothing at all

0.5 Very, Very Light

1 Very Light2 Fairly Light3 Moderate4 Somewhat

Hard

5 Hard67 Very Hard8910 Very, Very

Hard (Maximal)

3-5 days per weekWalking, cycle, arm ergometry,

warm-up and cool down20-90 minutes per session Intensity to achieve patient goalsUpper extremity exercise with lower

extremity (arm ergometer)Strength Training-Hand weights, free

weights, machine weights

3 days per weekCycling or walking> 3o minRPE 4-6 or predetermined MET levelArm ergometer, free weights, elastic

bandsStrength training-2-4 sets 6-12 reps

6 Min Walk Test-Widely used tool to determine exercise prescription

Determine initial exercise intensity

F.I.T.T PRINCIPLEFrequency Intensity Time Type

FREQUENCY3 to 5 times per week

INTENSITY4-6 Borg Dyspnea scale12-14 RPE scale

INTENSITYDYSPNEA SCALE (Modified Borg)

0 None 5 Severe0.5 Very, Very slight 61 Very slight 7 Very

Severe2 Slight 83 Moderate 9 Very, Very

Severe4 Somewhat severe 10

Maximum

67 very, very light89 very light1011 light1213 somewhat

hard

1415 hard1617 very hard1819 very, very hard20

INTENSITYINTENSITYRPE SCALERPE SCALE

TIME20 to 6o minutesCan use interval training especially

for beginners or low level patientsTotal exercise time is most important

TYPEContinuous AerobicHigh Intensity Interval Training not

found to have same benefits as with Cardiac Population (CHF, etc)

Possibly due to DyspneaLow to moderate intensity interval

training can be usedResistance Training

No data for “optimal” resistance training program

Important to help maintain muscle mass (muscle wasting)

1-3 sets8-12 repetitions2-3 days per week

Exercise capacity often limited by dyspnea, not MET level or RPE, etc

SaO2 MonitoringSupplemental O2 to maintain 88%-90%Generally, cycle or other non weight

bearing equipment has higher O2 satsConsider continuous exercise on cycle,

recumbent stepper, etc. Interval on TM

Take bronchodilators prior to exercise

Short term benefits from PRSmaller improvements and shorter

lastingTypically more dyspnea than

obstructive diseaseGenerally more reliant on

supplemental O2

Careful to maintain O2 sats above 88%-90%

Monitor BP and HRConsider telemetry monitoringExercise Intensity should be light to

moderate ONLYMonitor for lightheadedness, chest

pain, etc

AACVPR and ACCP do not recognize IMT as part of Pulmonary Rehab

Devices used to impose resistance or load

Patients increase inspiratory muscle strength

Significant decreases in dyspnea Increased walking distance However, no increase in peak power Increased quality of life measures

Exercise Prescription is an Art!!Every patient is different

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American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign, IL; Human Kinetics, 2010.

Garvey C, Fullwood MD, Rigler J. Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Lung Disease. JCRP 2013; 33: 314-322

Johnson-Warrington V, Harrison S, Mitchell K, et al. Exercise Capacity and Physical Activity in Patients With COPD and Healthy Subjects Classified as Medical Research Council Dyspnea Scale Grade 2. JCRP 2014; 34(2): 150-154

Ryerson CJ, Cayou C, Toop F, et al. Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study. Respir Med 2014; 108(1): 203-210

Spruit MA, Singh SJ, Garvey C, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. Am J Respir Crit Care Med 2013; 188(8): e13-e64