Pulmonary Rehabilitation in COPD

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Pulmonary Rehabilitationin COPD
Maureen Fagan Respiratory Specialist Nurse
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Amy Winehouse diagnosed with emphysemaFrom
Times Online June 23, 2008
They tried to make me go to rehab, I said no,
no, no....
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What is Pulmonary Rehabilitation?

• a multidisciplinary programme of care for
  patients with chronic respiratory impairment that
  is individually tailored and designed to optimise
  each patients physical and social performance
  and autonomy.

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Spiral of Disability
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Why is it pulmonary rehabilitation important?

• COPD causes 30,000 deaths per year and leads to
  extensive morbidity. It incurs massive costs in
  relation to hospital admissions, incurring nearly
  6 times as many bed days of inpatient care as
  asthma.
• Interventions which improve quality of life and
  level of functioning are important since few
  interventions except smoking cessation affect
  disease progression.

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Development of Disability in COPD

• The decline in airway function may go unnoticed
  initially as people adapt their lives to avoid
  dyspnoea
• Up to 50 of FEV1 may be lost before a person
  presents with significant symptoms
• Significant disability develops late in the
  course of the disease when reversal of airway
  obstruction is not possible.
• Dyspnoea , Limb muscle dysfunction, hypoxaemia ,
  poor nutrition, steroid myopathy and loss of
  confidence may contribute to disability

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Aims

• Increase exercise tolerance
• Increase muscle strength and endurance
• Reduce dyspnoea and perception of breathlessness
• Reverse deconditioning
• Increase knowledge of lung condition and
  management of the disease
• Promote self-management and coping strategies
• Improve health-related quality of life
• Improve confidence in ability to exercise
• Increase independence in daily functioning
• Promote long-term commitment to exercise

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Who is it for?

• All disease severities (but may not benefit if
  unable to walk)
• where SYMPTOMS AND DISABILITY are present
  (usually MRC grade 3)

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Who is it for?

• All disease severities (but may not benefit if
  unable to walk)
• where SYMPTOMS AND DISABILITY are present
  (usually MRC grade 3)
• No justification for selection on basis of age,
  impairment, disability, smoking status or oxygen
  use
• Post exacerbation
• Contra-indicated if recent MI/ unstable angina/

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Course Content and Duration

• The longer the better but usually 6-12 weeks
• Twice weekly minimum
• Patient assessment
• Baseline and outcome assessments exercise
  capacity (shuttle walk), disability/health status
  (questionnaire)
• Exercise training upper limb and lower limb
  training/ respiratory muscle training / breathing
  exercises
• Optimal pharmacological management
• Educational support - can include carer
• Psychological support - can include carer
• Assessment of outcome
• Programme evaluation
• Maintenance

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Programme settings staffing

• Effective in inpatient, outpatient and community
  settings and possibly at home.
• Should be held at times that suit patients in
  buildings that are easy to access with
  appropriate access for those with disabilities.

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Patient Safety

• Staff patient ratio
• Exercise 18
• Education 116
• Staff trained in Basic life support
• Ambulatory O2

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Exercise Training Which muscle groups?

• Lower limb training improves exercise tolerance
  though no effect on measured lung function
• Upper limb training improves arm strength and
  reduces ventilatory demand
• Respiratory muscle training may influence
  endurance and dyspnoea but evidence is
  conflicting
• DOESNT HAVE TO BE HI TECH

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Education Programme

• COPD overview
• Breathing control, pacing and relaxation
• Exercise/activity
• Medication, devices and O2 therapy
• Managing exacerbations
• Sputum clearance
• OT equipment
• Benefits agency
• Holidays
• Palliative care
• Diet

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Psychological components

• COPD is associated with anxiety and depressive
  symptoms which may interfere with activities of
  daily living (ADLs)
• Expert opinion supports the use of educational
  and psychological interventions in pulmonary
  rehab programmes
• Typical goals address depression/anxiety, teach
  relaxation skills, coping strategies, discuss
  relevant issues such as sexuality, family and
  work relationships

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Patient Feedback

• Programme as a whole was excellent
• Wished it was longer
• Have got my life back
• Im now in control
• Much more confident
• Achieved goals and more
• Can relax better
• My illness no longer runs my life
• Can walk further
• My life now feels worth living again
• Feel better about myself

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Summary - Benefits of Pulmonary Rehabilitation

• Improved exercise capacity (Evidence A)
• Improved health-related quality of life (Evidence
  A)
• Reduces perceived intensity of breathlessness
  (Evidence A)
• Reduced hospitalisations and length of stay
  (Evidence A)
• Reduced anxiety and depression associated with
  COPD (Evidence A)
• Increased survival (Evidence B)
• Benefits probably extend well beyond the period
  of rehab, especially if exercise training is
  maintained at home. (Evidence B)
• Improved psychological wellbeing (Evidence C)

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References

• NICE National clinical guidelines on management
  of COPD in adults in primary and secondary care
  (2010)
• GOLD Global strategy for the diagnosis,
  management and prevention of chronic obstructive
  pulmonary disease (2009)
• Nici et al. ATS/ERS Pulmonary Rehabilitation
  Writing Committee American Thoracic
  Society/European Respiratory Society statement on
  pulmonary rehabilitation.  Am J Respir Crit Care
  Med. 20061731390-413
• Y Lacasse, L Brosseau, S Milne, S Martin, E Wong,
  GH Guyatt, RS Goldstein, White J, Pulmonary
  rehabilitation for chronic obstructive pulmonary
  disease (Cochrane review). In The Cochrane
  Library, issue 3, 2004.
• Pulmonary Rehabilitation Joint ACCP/AACVPR
  Evidence-Based Guidelines. Chest/ 112 / 5 /
  November 1997

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Resources

• GPIAG Best Practice Statement
• www.gpiag.org/resources/gpiag_pul_rehab_bestpracti
  ce.200306.pdf
• IMPRESS Principles Document
• www.ipmpressresp.com/portals/o/IMPRESS/Principleso
  fPR.pdf
• Patient Information
• http//www.chss.org.uk/chest/index.php

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• Thanks for listening.
• Any Questions ?