pulmonary rehabilitation - new patient · phlegm, rare wheeze ... 6 rcts; 219 copd patients...

Pulmonary Rehabilitation

Paul Hernandez, MDCM, FRCPCRespirologist and Medical Director

Pulmonary Rehabilitation Program

QEII Health Sciences Centre

Associate Professor of Medicine

Dalhousie University


Faculty Disclosure:

• Dr. Hernandez has participated on medical

advisory boards, conducted CME activities and/or

industry-sponsored clinical research for the

following companies:

Actelion, AstraZeneca, Boehringer Ingelheim, Eli

Lilly, GlaxoSmithKline, Merck Frosst, Novartis,

Nycomed, Pfizer, ZLB Behring


Learning Objectives:

Know who to refer for pulmonary rehabilitation

Know the benefits of pulmonary rehabilitation

Understand the typical treatment modalities

used in pulmonary rehabilitation

Become aware of new approaches to improve

exercise training in pulmonary rehabilitation

Treatable. Preventable.


Case Study: Ms. Jones

• 64 y.o. woman, retired journalist

• Ex-smoker for 5 years (40 pack years)

• Known severe COPD

• Dyspnea with routine household chores, daily cough, scant phlegm, rare wheeze

• 2-3 acute exacerbations per year

• Hospitalization 6 months ago

• PMHx: hypertension


• Meds: Tiotropium 18 mcg OD;

Fluticasone/Salmeterol 250/50

mcg BID; Salbutamol QID prn;

HCTZ 25 mg OD

• Exam: no cyanosis or clubbing,

mild accessory muscle use; Ht.

165 cm, Wt. 48 kg (BMI 18); RR

24/min, HR 105/min, BP 135/75

mmHg, SpO2 90%; signs of

severe airflow obstruction; JVP 3-

4 cm, minimal bipedal edema

Spirometry values:

• FEV1 45% predicted,

• FVC 55% predicted

• FEV1/FVC 60%

1 2


Volume (L)

Q1. Is her COPD optimally managed?

Q2. Is there evidence of “systemic

manifestations” of COPD?

Q3. Which non-pharmacological therapies

would be of benefit?


Key Message

Comprehensive Management of COPD

Clinical Course o COPD

Breakdown of Limiting Symptoms in COPD Patients at Peak Exercise

Skeletal Muscles in COPD


Who to Reefer to Pulmonary Rehabilitation

Who to Refer to Pulmonary Rehabilitation?

Symptomatic chronic lung disease affecting quality of life despite optimal medical therapy

obstructive lung diseases (COPD, asthma, CF)

interstitial fibrosis

lung transplantation (pre, post)

lung volume reduction surgery (pre, post)

obstructive sleep apnea/obesity hypoventilation

lung cancer

pulmonary hypertension


Benefits of Pulmonary Rehabilitation

Comorbidities Associated with COPD

PULMONARY REHABILITATION

What are the health benefits of exercise training?

Reduction of all cause mortality

Reduction of cardiovascular events

Improved diabetic control

Improved hypertension control

Improved lipid profile

Weight reduction

Improved psychological well-being

Improved health-related quality of life

Reduced health care utilization

Pulmonary Rehabilitation Following AECOPD

6 RCTs; 219 COPD patients

Pulmonary rehabilitation (including exercise, of any duration) versus conventional care following AECOPD

Significantly reduced:

Hospital admissions - pooled OR 0.13 (0.04-0.35); NNT 3 over 34 weeks

Mortality pooled OR 0.29 (0.10-0.84); NNT 6 over 107 weeks

Significantly improved HRQOL:

CRQ weighted mean differences in dyspnea, fatigue, emotional function & mastery 1.15 -1.88

Puhan M, et al. Cochrane Database Syst Rev 2009; (1):CD005305 (ISSN:1469-493X.

Just Do It!

Survey

1999

Survey

2005

Number of

programs 44 98

National

capacity 4500 8900

% COPD

population

being served0.5 1.2

Pulmonary Rehabilitation in Canada

Brooks et al. CRJ 1999; 6: 55-63.

Brooks et al. CRJ 2007; 14: 87-92.


Program structure

Where (inpatient, outpatient, home)

Duration (4 - 24 weeks)

Frequency (2 -5 per week)

Staff (coordinator, physician, physiotherapist,

nurse, dietitian, occupational therapist,

psychologist, respiratory therapist, pharmacist)

Facilities (gym, treadmills, cycle ergometers,

weights, mats, changing rooms, classroom,

rescucitation equipment, oxygen)


Program personnel

Program Coordinator/Manager

Physician (Respirologist)/Medical Director

Respiratory Nurse Specialist

Physiotherapist

Dietitian

Respiratory Therapist

Others: Psychologist, Occupational Therapist, PFT laboratory technologist, Secretary


Infrastructure

Exercise training equipment, gym, and track

Exercise testing equipment

Resuscitation equipment

Oxygen gas supply

Scales, pulse oximeters, sphygmomanometers

Telemetry

Audiovisual equipment and classroom

Office furniture, computers

Pulmonary Rehabilitation ProgramQEII Health Sciences Centre

First group started in 1997

12-week program with continuous intake dates

12-15 participants at a time

Participants with a respiratory diagnosis who remain symptomatic despite medical management

Exercise stress test done prior to intake

2 exercise, 1 education sessions weekly

Equipment: treadmills, recumbent bikes, upright bikes, arm ergometers, free weights, walking track

Current wait time ~2 to 3 months

Outpatient Pulmonary Rehabilitation

PPMC, Hôpital LavalMontreal Chest Institute

St-Paul’s Hospital

CH Mont-Sinaï

Halifax Infirmary

CRMSBC

Hôpital CHA Enfant-Jésus

Jewish Rehabilitation Centre

252 patients

Exercise

2 months

Maintenance

10 months

Hospital vs. Home-Based

Study design

Maltais et al. Can Respir J. 2005;12:193-198.

Group

education

program

Outpatient rehabilitation

Home rehabilitation

Randomization

CRQ dyspnea at 1 year

Outpatient

Home

Home - Outpatient

MCID MCID

-1.0 -0.5 0.0 0.5 1.0

Maltais, Bourbeau et al. Ann Intern Med. 2008; 149:869-78


Results: Dyspnea

SGRQ at 3 months


Results: Health Status

Outpatient

Home

Home - Outpatient

MCID MCID

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

Maltais, Bourbeau et al. Ann Intern Med. 2008; 149:869-78


Components of a Pulmonary Rehabilitation Program


Patient Education Sessions

Lung structure and function

Energy conservation

Coping with stress

Nutrition and lung disease

Respiratory medications/equipment

Action plan for acute exacerbations

Physical therapy/caring for your lungs

Psychosocial aspects (support network, sexuality, end-of-life decisions)


Smoking Cessation – Physician’s Role


Self-Management Education: Reduces Hospitalization

Exercise Training: How?


Exercise training

Exercise prescription individually tailored

determined by patient goals and initial CPET

Frequency (/week): 2-3 supervised, 2-5 at home

Intensity 50-80% VO2max (target HR/RPE)

Training session = 5-10 min warm-up; exercise

30-45 min at THR or RPE; 5-10 min cool down

Enjoyable exercise modalities for legs and arms

Patients taught to monitor own HR and RPE

Supplemental O2 by NP to keep SaO2 > 88%

F

I

T

T

Effect of Exercise Training Intensity

Casaburi et al ARRD 1991

Attaining Exercise Training Targets

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

0

20

40

60

80

100

Training weeks

Tra

inin

g in

ten

sit

y(%

Wm

ax)

0

15

30

1 2 3 4 5 6 7 8 9 10 11 12

0

15

30

Training weeks

Tra

inin

g t

ime (

min

)

Maltais F, et al. AJRCCM 1997; 155:555-61.

Strategies to Improve Exercise Training

Increase muscle performance:

• endurance training

• interval training

• strength/resistance training of

peripheral muscles

• neuromuscular electrical

stimulation of peripheral muscles

• pharmacological approaches

(anabolic steroids, growth

hormone)

• nutritional supplementation

• inspiratory muscle training

Ventilatory load/drive:

• optimizing pharmacological

management

• biofeedback

• supplemental oxygen

• supplemental heliox

• NIVS

Interval training

Coppoolse, et al. ERJ 1999; 14:258.

STRENGTH: n=2470% 1-RM: 3x8 repetitions

n=48 6 upper and lower extremity muscle groups

ENDURANCE: n=2460% Wmax + 60% Wspeed

40 minutes exercise time

12-week out-patient rehabilitation: 36 sessions

Strength vs. Endurance Exercise Training

Spruit et al. ERJ 2002; 19:1072-1078.

0

10

20

30

40

50

6MWD VO2max CRDQ

STRENGTH

ENDURANCE

(% initial or

point

s)

Spruit et al. ERJ 2002; 19:1072-1078.

Bourjeily-Haber, et al. Thorax 2002; 57:1045-1049.

Peripheral Neuromuscular Electrical

Stimulation

RESPIRATORY MUSCLE TRAINING

Threshold loading device Resistive breathing device

PImax (cm H2O)

Endurance (sec)

Endurance (cm H2O)

6MWD (m)

Dyspnea (Borg)

Dyspnea (TDI)

11

154

10

48

-1.5

+2.7

0.001

0.01

0.001

0.11

0.01

0.01

Effect size p value

Lötters et al. ERJ 2002; 20:570-576.

RESPIRATORY MUSCLE TRAINING

Combining Pulmonary Rehabilitation and LABD

Palange P, et al. J Appl Physiol 2004; 97:1637-1642.

Flow-volume curves for 2 representative COPD patients (A and B) on air (left) and on heliox (right)

Heliox and Exercise in COPD

Changes in operational lung volumes during exercise, on air ({blacksquare}) and on heliox ({square})



Mean rates (SD) of increase in VE and VCO2 output during constant work rate exercise on air (solid) and on heliox (open) in COPD (n = 12)



Inspiratory Pressure Support

during Exercise Training in COPD

Van 't Hul, et al. ERJ 2006;27:65-72.

Van 't Hul, et al. ERJ 2006;27:65-72.


during Exercise Training in COPD


during Exercise Training

Van 't Hul et al Eur Respir J. 2006;27:65-72

Van 't Hul, et al. ERJ 2006;27:65-72.

Cycle Endurance

• 29 Subjects

• Mean age 70 yrs

• Mean FEV1 1.1L

• Ventilatory limited

• 8-week cycle

exercise program


during Exercise Training

Van 't Hul, et al. ERJ 2006;27:65-72.

Shuttle Walk Test• No significant

difference in

effect on

HRQoL (SGRQ)


Maintenance

Ries AL, et al. AJRCCM 2003; 167:880-8.

172 graduates of PRP randomized to 12-month

maintenance (weekly telephone calls + monthly sessions)

vs. standard care. Modest improvements at 12-months.


Outcome measures

Dyspnea (CRDQ-dyspnea, BDI/TDI, MRC, VAS)

Exercise performance (CPET, 6-MWT, Shuttle walk test)

Health-related quality of life (SF-36, CRDQ, SGRQ)

Cardiovascular risk factors (BMI, body composition, BP, lipids, smoking status, HbA1C )

Patient satisfaction (questionnaire)

Health care utilization (hospitalizations, ER visits)

Long-term clinical outcomes (maintenance, survival)


Participant Feedback

“This program has been helpful not only from the exercise and educational aspects, but also as a support system. It has been very helpful being around people who share similar challenges due to lung issues even though those issues are caused by different medical problems. It is easy to feel isolated, at times anxious and depressed, when you are battling a disability that affects all aspects of your life. Being around people with the same problems helps you to fight harder, try to achieve a little more because we encourage and support each other whilst having an understanding of how day to day activities are harder due to health issues. All staff members of this program have offered encouragement, support, advice and a great sense of humour for which they are to be thanked!”

Pulmonary rehabilitation participant – QEII Health Sciences Centre, Halifax NS – Feb 2009


Take home messages:

All symptomatic, stable patients with chronic lung

disease may benefit from pulmonary rehabilitation

Pulmonary rehabilitation involves exercise training,

education and nutritional counseling

The benefits of pulmonary rehabilitation include less

dyspnea, improved exercise tolerance and improved

health-related quality of life

pulmonary rehabilitation - new patient · phlegm, rare wheeze ... 6 rcts; 219 copd patients...

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