Transcript PULMONARY REABILITATION - Ligue Nationale contre la

PULMONARY REABILITATION
A. CHABBOU
MD MP
Journées Scientifiques:
SOUSSE LE 25 FEVRIER 2006
PULMONARY REABILITATION
Rationel
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The limitations of the patient with COPD
Deconditioning
) impact on skeletal muscle
Systemic manifestations ) and cardiovscular system
muscle dysfunction
EXERCISE
LIMITATIONS
inability to increase oxygen delivery to the
peripheral muscle
Pulmonary hypertension
During exercice
Constraints on lung mechanics
(dynamic hyperinflamation
and flow limitation)
gaz exchange
inefficiency in
the lungs
Cardio vascular
Limitation
Limitations are - cardiovascular
- pulmonary
- and skeletel muscle
Pulmonary limitations
PULMONARY REABILITATION
Skeletal muscle dysfunction :
- déterminant factors
- complementary mechanisms :
1-  muscle strength  exercise traning
2-  muscle endurance
3- impaired muscle oxidative capacity
-  activity of the enzymes : citrate synthase
hydrooxy acetyl
COA deshydrogenase
4- a shift toward a glycolytic fiber type distribution (low fraction of type I fibers)*
skeletal muscle endurance
 fatigability   exercise training
Lowering of the lactate threshold
 ventilatory requirements during exercise
PULMONARY REABILITATION
Skeletal muscle dysfunction*
Proportion of type-IIA fibres % 29.4¡12.1 34.8¡11.9
Proportion of type-IIXfibres % 27.2¡12.345.8¡18.9**
CSA of type-IIX fibres mm2 4248¡1300 2566¡1137**
P<0.001
Myopathological features in skeletal muscle of patients with chronic obstructive pulmonary disease
H.R. Gosker*, B. Kubat#, G. Schaart}, G.J. van der Vussez, E.F.M. Wouters*, A.M.W.J. Schols*
PULMONARY REABILITATION
Complementary mecanisms
1- The sedentary life style of COPD patients  skeletal muscle atrophy at 2 levels :
The whole muscle level
The myocyte level
With indirectly : the loss in fat-free mass
2- Systemic inflammation **:
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recent studies have underlined the importance of systemic inflammation as a mechanism for
developement of muscle weakness, especially during severe exacerbations of COPD
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Circulating levels of IL8 : are significantly correlated with muscle weakness
Weight loss, especially fat-free mass has been associated with systemic inflammation
 levels of skeletal muscle apoptosis were observed in patients presenting with weight
loss
Oxidative stress is another factor related to the process of muscle wasting.**
Patients with COPD are exposed to  levels of oxidative stress :
when stable
and during exacerbations
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Systemic inflammation
Nitrite and nitrate levels in patients with chronic obstructive
pulmonary disease ( ) and control subjects ( ). *: p<0.05; **: p<0.01.
Skeletal muscle inflammation and nitric oxide in patients with COPD
M. Montes de Oca1, S. H. Torres2, J. De Sanctis3, A. Mata1, N. Hernández2 and C. Tálamo1
Eur Respir J 2005; 26:390-397
PULMONARY REABILITATION
Systemic inflammation
Endothelial constitutive nitric oxide synthases (eNOS), inducible isoform nitric oxide synthases (iNOS) and
nitrotyrosine levels in patients with chronic obstructive pulmonary disease ( ) and control subjects ( ). ***:
p<0.001.
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Systemic inflammation
Tumour necrosis factor (TNF)- levels in patients with chronic obstructive pulmonary disease
( ) and control subjects ( ). #: p<0.0001.
Table. — Skeletal muscle levels of inflammatory markers in low and normal
weight chronic obstructive pulmonary disease(COPD)
Variables
Low weight COPD
Normal weight COPD
P-value
Nitrites µmol·mg–1 protein
11.4±2.0
13.6±3.1
NS
Nitrates µmol·mg–1 protein
19.5±2.2
24.5±2.9
NS
Total µmol·mg–1 protein
30.9±3,5
34.3±2.8
NS
Nitrotyrosine ng·mg–1 protein
24.5±6.9
25.2±0.1
NS
iNOS ng·mg–1 protein
27.1±7.6
36.6±9.4
NS
eNOS ng·mg–1 protein
32.2±6.2
31.9±3.1
NS
nNOS ng·mg–1 protein
85.3±18.4
101.7±23.1
NS
pg·mg–1 protein
201±93
267±207
NS
CD163 ng·mg–1 protein
6.4±0.7
6.8±2.7
NS
CD154 ng·mg–1 protein
14.3±5.9
17.6±8.5
NS
TNF-
PULMONARY REABILITATION
Systemic inflammation
Transversal section of the vastus lateralis part of quadriceps muscle.
Immunohistochemical reaction with anti-CD68, clone MB11.
a) Control subject, male aged 68 yrs. The black dots are muscle fibres and
endothelial cell nuclei.
b) Chronic obstructive pulmonary disease patient, male aged 68 yrs. The black
stain represents macrophages infiltrate. Scale bar = 50 µm.
Oblique section of vastus lateralis part of quadriceps muscle in a 70-yr old female
chronic obstructive pulmonary disease (COPD) patient. b) Longitudinal section of
vastus lateralis part of quadriceps muscle in a 69-yr-old female COPD patient.
Arrows show prolongations of macrophage surrounding capillary. M: macrophage;
NM: nucleus of macrophage; F: muscle fibres; NF: nucleus of muscle fibre; C:
capillary; NE: nucleus of capillary endothelial cell; P: pericyte. Scale bars = 1 µm.
Skeletal muscle dusfunction*
PULMONARY REABILITATION
Exercice intolerance : Multifactorial
Impairment of lung mechanics
Altered gaz exchange
Impairment of respiratory muscles
Cardiac dysfuntion
Deconditioning
Poor nutritional status
Psychological problems
PULMONARY REABILITATION
Disease  Deficiency  Incapacity  Handicap
COPD Aw obstruction  dyspnea  prostration
COPD
Bronchodilatation
Tolerance
PULMONARY REHABILITATION
Move
PULMONARY REABILITATION
Goals
- General : Improve physical and psychological or
emotional functioning of patients in interaction with
theire environment
- Specific :
- Reduce symptoms
- Improve activity and daily function QOL
- Restore the highest level of independant function (in
every day activities)
- Enhance knowledge of the disease
- Improve self-management
Non pulmonary problems
Not addressed by medical therapy
PULMONARY REABILITATION
Components of the rehabilitation program
1- Optimal medical treatment
2- Smoking cessation
3- Exercise training
4- Breathing retraining
5- Chest physiotherapy
6- Education
7- Psychological aspects and support
8- Nutritional therapy
9- Nursing care
10- Miscellaneous
PULMONARY REABILITATION
Exercise Training
Limitations
inability toO2
delivery to muscles
Needs
Exercise Training
Adapted to the
Individual
inefficiency of
gaz exchange
lung mechanics
hyper inflation
flow limitation
Training programs
that stimulates
cardiovascular and
skeletal muscle
pulmonary
hypertention
during exercise
muscle dysfunction
PULMONARY REABILITATION
Exercise training
- Lower extremity training : lower
limbs exercise
- Upper extremity training : arms
exercise
- Respiratory muscles training :
respiratory muscles exercise
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Exercise training
Modalities
Inpatient setting
Out patient setting
Community based setting
Home based setting
Inpatient setting
- transdisciplinary team
- favorable environnement and climate
- Patient entire disponibility
- 24 houres prolonged and tight management for
weak patients
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Exercise training
1- Methods
Cycle ergometer
Walking (Treadmill)
Better physiological benefit when exercise above a «critical level of intensity»
2- Patients selection*
Preliminary exercise test
Resting respiratory function measurements (poor correlation)
3- Type of exercise :
- intensity**
- endurance
4- Duration : No ideal duration established
8 weeks : common duration***
5- Results : Physiological change : ****
 blood lactate
 ventilation
 endurance
After high work rate training programs
-
PULMONARY REABILITATION
Exercise training
Duration of programs
Key Goal change the patient’s behavion from a sedentary toward a
more active life style
Measurable physiological
changes : weeks
behavioral
changes months
Longer duration
Better long term effect
> 8 weeks
6 months > 3 mouths
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Results
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Increase in maximal exercise performance
Physiologic adaptations in peripheral muscles
Improve of cardiac function
Reduction in ventilation and lactate levels at identical exercise
work rates
length
Long term
effects
Maintenance
indefinite
4-12 weeks
12 months
+
PULMONARY REABILITATION
Exercise training
Upper extremity Training
- Improve arm muscles function
- Does not improve exercise
tolerance
- Does not improve QOL
PULMONARY REABILITATION
Exercise training
Outcome measures : exercise testing
COPD patients mean age : 60 years
Most COPD patients are past smokers
COPD patients are at risk of other tobaco-related diseases : ischemic cardiac diseases, arteriel HT, cardiac arrhythmias
Stress test for coronary disease :
1 death/5000
1 major complication/1000
Exercise testing in COPD patients : 1/3 arterial blood
desaturation (SaO2 < 89 %) not predicted by rest spirometry
nor CO diffusing capacity
Need of a preliminary exercise test
PULMONARY REABILITATION
Exercise training
Outcome measures : exercise testings
Types of exercise tests
1- Submaximal exercise tests
cycle or treadmill
at a constant fraction of maximal work rate > 60 %
of the peak V 02
at low intensity, below to the lactic acidosis
threshold
Measures exercise endurance
Measurements : endurance time, heart rate,
respiratory rate, blood pressure, ECG, SaO2,
exhaled gazes, inspiratory capacity
Exercise training
Out come measures : exercise testing
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2- Six minute walk test
Walks at his own pace
Simple, well tolerated and relevant to daily activites
But varies upon encouragement and coaching and
should be standardized
3- Shuttle walk test
Walk up and down a 10 m distance with increasing
speeds dictated by a beep
Measures more exercise capacity than endurance
But self pacing is eliminated
Reproductible and correlates well with VO2 peak
during increamental treadmill exercise ( r = 0,88)
Exercise training
Outcome measures : exercise testing
Type of exercise tests
4- Incremental exercise tests
- bicycle or treadmill
- Measurements : Heart rate, respiratory rate,
blood pressure, ECG, SaO2, dyspnea, leg fatigue,
minute ventilation, oxygen consumption, CO2
production, anaerobic threshold and dead space
- Equipment problems :
- Cost of the test : 30
- Cost of equipement/test : 10
PULMONARY REABILITATION
Level of Handicap
Deficiencies
Respiration
-
A Obstruction
P.Elasticity
Gaz exchange
Assessement Measures
FEV1
FRC
IC
DLCO
PaO2, PaCO2, SaO2
Muscle
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Respiratory
Limbs and arms
MIP
MEP
Incapacity
Dyspnea
Exercise
Disadvantage
(handicap)
Life socio-professional
- Questionaires
- Walk test 6 min
- Endurance test
- Exercise fonctional tests
QOL questionaires
PULMONARY REABILITATION
Exercise Training
Specific strategies to increase training intensity
Neuromuscular electrical stimulation (NES)
Specific muscle groups of lower limbs are activated with low-intensity
electrical current
2 trials of transcutaneous neuromuscular electrical stimulation of lower limbs
in severe muscle weakness in stable patients  - significant - muscle
strength
- exercise capacity
1 study : faster functionnal recovery in patients with respiratory failure
under mechanical ventilation, bed bound for > 30 days.
Zanotti E, Felicetti G, Maini M, Fracchia C. Peripheral muscle
strength training in bed-bound patients with COPD receiving mechanical
ventilation : effect of electrical stimulaiton. Chest 2003;124 : 292-296
NES is safe and can be conducted at home
Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ. Home
based neuromuacular electrial stimulation as pulmonary rehabilitation in chronic obstructuve pulmonary disease. Troosters et al
PULMONARY REABILITATION
Exercise Training
Specific strategies to increase training intensity
Breathing exercises
Diaphragmatic breathing : Decreases breathing efficiency
pursed lip breathing
Increases gaz exchange, increases tidal
volume, reduces inspiratory time, reduces dyspnea, reduces end
expiratory volumes
Effectineness assessed by SaO2
Bianchi R, Gigliotti F, Romagnoli I. Chest wall kinematics and breathlessness during
pursed-lip breathing in patients with COPD. Chest 2004 ; 125 : 459465.
Breslin EH. The pattern of respiratory muscle recruitment during pursed-lip breathing. Chest
1992 ; 101 : 75-78
PULMONARY REABILITATION
Exercise Training
Specific strategries to increase training intensity
O2 supplementation
Controversial
O2 supplementation
- Reduces the ventilatory requirement for a given work rate
increases maximal exercises tolerance
Reduces exercise – ruduced pulmonary hypertension
Studies did not show additional benefit
O2 could enhance training intensity in patients with COPD
Funther studies
PULMONARY REABILITATION
Exercise Training
Specific strategies to increase training intensity
Non invasive Mechanical Ventilation(NIMV)
reduces the inspiratory muscles load.
Usefulness only in severily impaired patients
Hawkins P, Johnson LC. Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease. Thorax
2002;57:853-859
Costes F, Agresti A, Noninvasive ventilation during exercise training improves exercise
tolerance in patients with chronic obstructive pulmonary disease. J cardiopulm Rehabil 2003;23:307-313
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NIMV at home associated to out patient exercise training 
additional increase in the shuttle walk distance
 QOL compared to training alone
Garrod R, Mikelsons C Paul EA. Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in
severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 162:1335-1341
PULMONARY REABILITATION
Exercise Training
Specific strategies to increase training intensity
Ergogenic drugs
Anabolic steroïds (AS)
Studies included only men
Drugs studied are oxandrolone, nandrolone, stanozolol and testosterone
All studies report an increase in body weight through a gain in lean body mass
4 studies : AS + PRH program
 Muscle strength

Effects of strength training
does not improve exercise endurance (muscle hypertrophy without capillary and
aerobic enzymes increase)
Protection against side effects of corticosteroïds
prostate hypertrophy, aProstate cancer, Hb > 16g. Dl -1, Renal disease, Congestive heart failure
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NI
Growth hormone/Insulin like growth hormone
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Disturbed anabolic/catabolic balance in COPD
Lack of evidence of benefits – high cost
Schols AM, Soeters PB, Mostert R, Pluymers RJ. Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary
disease : a placebo controlled randomized trial. Am J Respir Crit Care Med 1995;152 : 1268-1274
PULMONARY REABILITATION
Components of the rehabilitation program
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Smoking cessation the key to the prevention and
treatment of COPD
Give up
- early stages interventions 
Reduced rate of FEV1 decline
- Function lost is however not regained
- Advanced disease, still valuable
Maintenance of abstinence :
 beyond the phase of acute withdrawal
 for extended periods thereafter
PULMONARY REABILITATION
Smoking cessation
Addiction
- Nicotine substitutes
- Psychological
- Behavioral
- Physiological
Hard to accomodate
the needs of every smoker
Strategies
Individual adapted programs
Rather than group programs
Pharmacological interventions
Behavioral interventions
PULMONARY REABILITATION
Education and self-management :
 Optimally control the disease
 Achive behavioral change
 Improve coping with the disease
Up to 75 % of patients have difficulties in understanding how and when to take their
inhalation medication
Goodman DE, Israel E, Rosenberg M, Johnston R, Weiss ST, Drazen JM. The influence of age, diagnosis, and gender on proper use
metered-dose inhalers. Am J Respir Crit Care Med 1994;150:1256-1261
Educational sessions
- Improve adherence to medication
- Help patients to deal with exacerbations
- Reduce hospital days
- Cost effective
- QOL
Helpful for patients with severe disease, Small groups-or individual
Gallefoss F, Bakke PS. Cost-benefit and cost-effectiveness analysis of self-management in patients with COPD : a 1-year follow-up
randomized, controlled trial. Respir Med 2002;96:424-431
PULMONARY REABILITATION
Psychosocial support
Rationale :
- Depression in COPD 2.5 fold higher/
general population
- 20-40 % of COPD present with anxiety and depression
- Spouses of COPD suffer from depression and stress
- Smoking cessation result in mood disturbance.
Psychological interventions improve mood distrubances
> exercise training only.
Can be associated to smoking cessation counselling,
support and to education. Enhance the chances for
sustained smoking cessation
PULMONARY REABILITATION
Improving activities of daily living
Occupational therapy
Occupational therapists interventions
aim to increase the patient functional
autonomy
Methods consist of exercise training
oriented toward daily living activities
(walking efficiency, ventilatory capacity..)
Wheeled devices (rollators) are useful but
expensive
They could be useful in severe diseases
PULMONARY REABILITATION
Nutritional Programs
- In COPD,
-  of body weight
- Loss of fat-free mass is related to morbidity and mortality
-  > 2 kg of body weight improve survival
-  resting energy expenditure 
Exercise traing may induce a negative protein balance
But – it is no sure that patients receiving nutritional supplements
would not distrub their regular nutritional habits with a
consecutive reduced calorie intake and risk of paradoxal
undernourishment.
- At the opposite, obese patients should undergo weight loss through
a dietary intervention without loosing fat-free mass.
PULMONARY REABILITATION
Miscellaneous
- Erythropoietin therapy
- antioxidant therapy (Vit E, Nacetyl cysteine)
- Brondilators associated to PRH 
 improvements in QOL
- In selected subpopulations  individualized
programs
- Does not concern all patients
- Physiotherapy - sputum drainage
PULMONARY REABILITATION
Use of health care resources
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Benefit of PRH is due to improved knowledge of the disease and
enhanced self-management rather to physiological improvements
Admissions are reduced by 40 % when a self management program
is followed despite significant physiological effects
No decrease in hospital days for long term exercise training without
individualized education sessions and self management strategies.
Engström CP. Long-term effects of a pulmonary rehabilitation programme in outpatients with
chronic obstructive pulmonary disease : a randomized controlled study. Scand J Rehabil Med
1999;31:207-213.
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Reduction in mild exacerbations may lead to stop disease
progression
Exacerbation frequency linked FEV1 decline
Donaldson GC. Relationship between exacerbation frequency and lung function
decline in chronic obstructive pulmonary disease. Thorax 2002;57:847-852
PULMONARY REABILITATION
Use of health care resources ( cost-effectineness)
necessity of long – term following
Reduction of hospitalization
 Griffithsetal patients with COPD spent fewer days
hospitalized during a 1 year follow-up period.
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Griffiths TL, Burr ML, Campbell IA. Results at 1 year of outpatient multidisciplinary pulmonary
rehabilitation : a randomised controlled trial. Lancet2000 ; 355 : 362 - 368
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Out patients PRH reduces hospital days but
studies lacked statistical power
Hospital days are the primary cost driver of COPD
care
Croxton TL, Weinmann GG, Senior RM. Clinical research in chronic obstructive pulmonary disease : needs
and opportunities. Am J Respir Crit Care Med 2003 ; 167 : 1142 - 1149
PULMONARY REABILITATION
Maintenance strategies
Several strategies have been tried to
maintain the benefits as long as possible
after graduation from PRH programs
- Continued 3 times weekly out patient  15 months
- Once week high – intensity exercise training sessions
- Exercise advise during the follow-up
- Repeated short programs
- Telephone support
- Once monthly follow-up visits
Maintenance programs seem to be
necessary after 6 weeks out patients or 6
weeks in patients.
After longer programs (6 months), benefits
could be prolonged for > 1 year.
PULMONARY REABILITATION
Survival
No study has convincingly shown evidence of improved survival after PRH
In 7 studies
PRH group
Control group
12 – 18 months
mortality risk
7.8 %
9.9 %
Nb death
23/315
28/283
Odds of dying in PRH
group
Relative risk,
0.69
0.38 – 1.25 ;
p =0.395
Best estimate : Rehabilitation reduces short-term risk of dying by 31 %.
Not statistically significant ( nb of patients insufficient, patients on PRH are in a
stable state)
Further studies
Conclusion
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In COPD muscle deficiency and flow
limitation lead to deficiency and handicap
PR enhances exercise capacity, improves
daily life activities and ameliorate QOL
A successful PR is scientific,
transdisciplinary, individualised and
sustained for at least 8 weeks
PR is cost effective
Further studies are needed for specific
added stategies