Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization

1
Pulmonary Rehabilitation in Chronic Lung Disease
Components and Organization

• Prof. Dr. Müzeyyen Erk
• Cerrahpasa Medical Faculty
• Chest Disease Dept.

2
Plan

• Chronic Respiratory Disease
• Definition
• Factors Contributing to Exercise Intolerance in
  CRD
• Pulmonary Rehabilitation
• Definition
• Patient Assessment and Selection
• Program Setting

3
Plan

• Chronic Respiratory Disease
• Definition
• Factors Contributing to Exercise Intolerance in
  CRD
• Pulmonary Rehabilitation
• Definition
• Patient Assessment and Selection
• Program Setting

4
Chronic diseases

• DefinitionAll 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

5
(No Transcript)
6
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

7
Daily physical activity pattern in COPD
Pitta et al. Am J Respir Crit Care Med.
2005171972-977
8
Chronic respiratory disease
Pulmonary phsiological abnormality
9
IC, exercise endurance and dyspnea
10
Dynamic hyperinflation during exercise in COPD
ODonnell D, Chest 2000
11
Body composition
Schols et al. ARRD 1993 147 1151-6
12
Peripheral muscle weakness in COPD
Bernard S et al. AJRCCM 1998 158 629-34
13
Structural changes in skeletal muscle in COPD
FEV1 32 PaO2 87
(Vastus Lateralis)

• Fiber type changes
• Atrophy
• Apoptosis

Richardson RS et al. AJRCCM 2004 169 89-96
14
Exercise capacity as a predictor of mortality
Oga T, et al. Am J Respir Crit Care Med
2003167544-549
15
Interventions aimed at improving exercise
capacity (i.e. quality of life)

• Oxygen
• Heliox
• Rehabilitation
• Bronchodilators
• LVRS

16
Plan

• Chronic Respiratory Disease
• Definition
• Factors Contributing to Exercise Intolerance in
  CRD
• Pulmonary Rehabilitation
• History
• Definition
• Patient Assessment and Selection
• Program Setting

17
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.

18
Definition

• 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.

ERS-ATS statement 2006
19
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
20
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 postpolio
  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 postlung transplantation, LVRS
• Pulmonary vascular disease

21
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 6674, 2006
22
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

Hill N.Proc Am Thorac Soc Vol 3. pp 6674, 2006
23
Setting for pulmpnary rehabilitation

• Pulmonary 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 components
• In Europe
• Ambulatory patients may be admitted to an
  inpatient program to undergo intensive therapy
• To avoid the inconvenience of daily travel

24
MULTIDISCIPLINARY TEAM PARTICIPATING ON A
PULMONARY REHABILITATION TEAM

• Physicians
• Pulmonologist
• Physiatrist
• Therapists
• Physical
• Occupational
• Respiratory
• Nurse or exercise physiologist
• Nutritionist
• Social worker
• Psychologist

TEAM
Hill N.Proc Am Thorac Soc Vol 3. pp 6674, 2006
25
Keys for successful pulmonary rehabilitation ?

• Patient selection
• Program components

26
PATIENT SELECTION

• ANY STABLE PATIENT WITH DISABLING SYMPTOMS
  (ACCP/AACVPR) ?
• PULMONARY FUNCTION ?
• AGE ?
• CO-MORBIDITY ?
• SMOKING ?
• PSYCHOSOCIAL CONDITIONS ?
• MUSCLE WEAKNESS ?

MODIFICATION
27
Components of a rehabilitation programme

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

Hill N.Proc Am Thorac Soc Vol 3. pp 6674, 2006
28
Main components of PR programmes Donner CF,
Decramer M. Pulmonary Rehabilitation ERJ
Monograph, 2000 13132-142
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
() No evidence, () Few evidences, ()
Good evidence, () Before transplantation
29
Topics often covered during group education
sessions

• Whats 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

Hill N.Proc Am Thorac Soc Vol 3. pp 6674, 2006
30
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)
• Reduced need for hospitalization
• Only in patients with COPD with severe airway
  obstr.

Hill N.Proc Am Thorac Soc Vol 3. pp 6674, 2006
31
Benefits of Pulmonary Rehabilitation in COPD
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
32
The vicious circle
Chronic Pulmonary Disease
Increased VE Requirements
Decreased VE Requirements
Physical Deconditioning
Physical Reconditioning
Immobility
Pulmonary Rehabilitation
Decreased Exercise Capacity
Increased Exercise Capacity
Increased Breathlessness
Decreased Breathlessness
Cooper. Med Sci Sports Exerc. 200133(7
suppl)S643-S646.
33
(No Transcript)