Transcript Slayt 1 - Toraks

Pulmonary Rehabilitation in Chronic
Lung Disease; Components and
Organization
Prof. Dr. Müzeyyen Erk
Cerrahpaşa Medical Faculty
Chest Disease Dept.
Plan

Chronic Respiratory Disease
 Definition
 Factors

Contributing to Exercise Intolerance in CRD
Pulmonary Rehabilitation
 Definition
 Patient Assessment
 Program
Setting
and Selection
Plan

Chronic Respiratory Disease
 Definition
 Factors

Contributing to Exercise Intolerance in CRD
Pulmonary Rehabilitation
 Definition
 Patient Assessment
 Program
Setting
and Selection
Chronic diseases
 Definition
“All 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
Factors limiting exercise
CENTRAL
• LUNG DYNAMIC
HYPERINFLATION
• REDUCED VENTILATORY
RESERVE
•  COST OF BREATHING
PERIPHERAL
• MUSCLE ATROPHY,
 CAPILLAR DENSITY
• POOR NUTRITIONAL STATE
• POOR BIOENERGETICS
• METABOLIC ACIDOSIS
Daily physical activity pattern in COPD
Walking
Standing
Healthy
elderly
(n=25)
11
COPD
patients
(n=50)
6
0%
Sitting
Lying
41
42
27
20%
Others
52
40%
60%
4
12
80%
100%
Pitta et al. Am J Respir Crit Care Med. 2005;171:972-977
COPD
Chronic
respiratory
Airflow obstruction
disease
Hypoxemia
Exacerbations
 Ventilatory
requirement
Tachypnea
Air trapping
Pulmonary
phsiological
abnormality
Hyperinflation
Anxiety
Dyspnea
Deconditioning
Activity limitation
Patient
Centered
Outcomes
Poor health-related quality of life
Cooper CB.
Am J Med 2006;
119(10A): S21-S31.
IC, exercise endurance and dyspnea
Inspiratory
Capacity
r=0.52
P<0.001
r=-0.50
P<0.001
Exercise Endurance
r=-0.61
P<0.001
Exertional
Dyspnea
O’Donnell et al. Eur Respir J. 2004;23:832–840
Dynamic hyperinflation during exercise in COPD
O’Donnell D, Chest 2000
Body composition
50
41%
40
(< 90% ideal BW)
% patients with low body weight
46%
30
27%
20
11%
10
0
R e s p . F a ilu re
(P a O 2 < 5 5 T o rr)
(n = 4 8 )
S e v e re C O P D
M o d e ra te C O P D
(F E V 1 < 3 5 % )
(F E V 1 3 5 -5 0 % )
(n = 1 1 2 )
(n = 5 6 )
M ild C O P D
(F E V 1 > 5 0 % )
(n = 3 7 )
Schols et al. ARRD 1993; 147: 1151-6
Peripheral muscle weakness in COPD
Bernard S et al. AJRCCM 1998; 158: 629-34
Structural changes in skeletal muscle in COPD
FEV1 %32
(Vastus Lateralis)



PaO2 87
Fiber type changes
Atrophy
Apoptosis
Richardson RS et al. AJRCCM 2004; 169: 89-96
Exercise capacity as a predictor of mortality
Proportion surviving
1.0
I
II
0.9
0.8
0.7
0.6
0.5
0.4
0.3
III
I: Peak VO2: >995 mL/min (n=37)
II: Peak VO2: 793 -995 mL/min (n=38)
IV
III: Peak VO2: 654 - 792 mL/min (n=38)
IV: Peak VO2: <654 mL/min (n=37)
0
12
24
36
48
60
Months of follow-up
Oga T, et al. Am J Respir Crit Care Med 2003;167:544-549
Interventions aimed at improving exercise
capacity (i.e. quality of life)





Oxygen
Heliox
Rehabilitation
Bronchodilators
LVRS
Plan

Chronic Respiratory Disease
 Definition
 Factors

Contributing to Exercise Intolerance in CRD
Pulmonary Rehabilitation
 History
 Definition
 Patient Assessment
 Program
Setting
and Selection
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.
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
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
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 post–polio 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 post–lung transplantation, LVRS
Pulmonary vascular disease
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 66–74, 2006
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 66–74, 2006
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
MULTIDISCIPLINARY TEAM PARTICIPATING ON
A PULMONARY REHABILITATION TEAM

Physicians



Therapists







Pulmonologist
Physiatrist
TEAM
Physical
Occupational
Respiratory
Nurse or exercise
physiologist
Nutritionist
Social worker
Psychologist
Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006
Keys for successful
pulmonary rehabilitation ?
Patient selection
 Program components

PATIENT SELECTION

ANY STABLE PATIENT WITH
DISABLING SYMPTOMS
(ACCP/AACVPR) ?

PULMONARY FUNCTION ?





AGE ?
CO-MORBIDITY ?
SMOKING ?
PSYCHOSOCIAL CONDITIONS
?
MUSCLE WEAKNESS ?
MODIFICATION
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 66–74, 2006
Main components of PR programmes
Donner CF, Decramer M. Pulmonary Rehabilitation ERJ Monograph, 2000: 13:132-142
Education
Psycosocial
support
General
exercise
training
Selected
muscle
training
Chest
physiotherapy
Occupational
therapy
Nutritional
intervention
COPD
+++
++
+++
++
+
++
+
Asthma
++
++
+++
CF & bronchiect.
++
++
+++(*)
+
+
Chest wall disor.
++
++(*)
+++
+
++
+
Neuromusc. dis
+
++
+
Respir sleep dis
+
++
Pre-post surgery
++
++
+++
++
+++
++
Tracheostom pat
++
++
+
+
+
+
+
+
+
Interst lung dis
(+): No evidence, (++): Few evidences, (+++): Good evidence, (*): Before transplantation
Topics often covered during group education
sessions






What’s 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 66–74, 2006
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)
1.
Reduced need for hospitalization*
* Only in patients with COPD with severe airway obstr.
Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006
Benefits of Pulmonary Rehabilitation in COPD
Improves exercise capacity
Reduces intensity of breathlessness
A
A
Improves HRQoL
Reduces hospitalizations
Reduces anxiety and depression
A
A
A
Improves arm function
Improves survival
Respir. muscle tra. (+ general exer)
Psychosocial intervention
B
B
C
C
GOLD Exc. Summ. 2008
The vicious circle
Chronic Pulmonary Disease
Increased VE
Requirements
Physical
Deconditioning
Decreased VE
Requirements
Physical
Reconditioning
Immobility
Pulmonary Rehabilitation
Decreased
Exercise
Capacity
Increased
Exercise
Capacity
Increased
Breathlessness
Decreased
Breathlessness
Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.