View
214
Download
2
Category
Tags:
Preview:
Citation preview
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 and Selection Program Setting
Plan
Chronic Respiratory Disease Definition Factors Contributing to Exercise Intolerance in CRD
Pulmonary Rehabilitation Definition Patient Assessment and Selection Program Setting
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 PERIPHERAL
• LUNG DYNAMIC HYPERINFLATION
• REDUCED VENTILATORY RESERVE
• COST OF BREATHING
• MUSCLE ATROPHY,
CAPILLAR DENSITY
• POOR NUTRITIONAL STATE
• POOR BIOENERGETICS
• METABOLIC ACIDOSIS
Daily physical activity pattern in COPD
Walking Standing Sitting Lying Others
6
11 41
27
42
52 12
0% 20% 40% 60% 80% 100%
Healthyelderly(n=25)
COPDpatients(n=50)
4
Pitta et al. Am J Respir Crit Care Med. 2005;171:972-977
Air trapping
Hyperinflation
Airflow obstruction
Poor health-related quality of life
Activity limitationDyspnea
PatientCenteredOutcomes
Anxiety
Tachypnea Ventilatory requirement
Deconditioning
COPDCOPD
Hypoxemia Exacerbations
Cooper CB. Am J Med 2006;
119(10A): S21-S31.
Chronic respiratory
disease
Pulmonary phsiological abnormality
IC, exercise endurance and dyspnea
InspiratoryCapacity
Exercise EnduranceExertionalDyspnea
r=-0.50P<0.001
r=-0.61P<0.001
r=0.52P<0.001
O’Donnell et al. Eur Respir J. 2004;23:832–840
Dynamic hyperinflation during exercise in COPD
O’Donnell D, Chest 2000
Schols et al. ARRD 1993; 147: 1151-6
0
10
20
30
40
50
11%
27%
41%
46%
Mild COPD
(FEV1 > 50 %)
(n=37)
Moderate COPD
(FEV1 35-50 %)
(n=56)
Severe COPD
(FEV1 < 35%)
(n=112)
Resp. Failure
(PaO 2 < 55 Torr)
(n=48)
% p
ati
en
ts w
ith
lo
w b
od
y w
eig
ht
(< 9
0%
id
ea
l B
W)
Body composition
Peripheral muscle weakness in COPD
Bernard S et al. AJRCCM 1998; 158: 629-34
Richardson RS Richardson RS et al. AJRCCM et al. AJRCCM 2004; 169: 89-962004; 169: 89-96
(Vastus Lateralis)
Fiber type changes Atrophy Apoptosis
Structural changes in skeletal muscle in COPD
FEV1 %32
PaO2 87
Exercise capacity as a predictor of mortalityP
ropo
rtio
n s
urv
ivin
g
Months of follow-up
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0 12 24 36 48 60
III
III
IV
I: Peak VO2: >995 mL/min (n=37)
II: Peak VO2: 793 -995 mL/min (n=38)
III: Peak VO2: 654 - 792 mL/min (n=38)
IV: Peak VO2: <654 mL/min (n=37)
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 and Selection Program Setting
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.
ERS-ATS statement 2006
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.
Definition
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 rehabilitationPulmonary 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 componentsIn 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 Pulmonologist Physiatrist
Therapists Physical Occupational Respiratory
Nurse or exercise physiologist
Nutritionist Social worker Psychologist
Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006
TEAM
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
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 ++ ++ + + + +
Main components of PR programmes Donner CF, Decramer M. Pulmonary Rehabilitation ERJ Monograph, 2000: 13:132-142
(+): 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
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
Benefits of Pulmonary Rehabilitation in COPD
The vicious circle
Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.
Chronic Pulmonary Disease
Physical Deconditioning
Physical Deconditioning
Physical Reconditioning
Physical Reconditioning
Decreased Exercise Capacity
Decreased Exercise Capacity
Increased Exercise Capacity
Increased Exercise Capacity
Increased Breathlessness
Increased Breathlessness
Decreased Breathlessness
Decreased Breathlessness
Immobility Pulmonary Rehabilitation
Increased VE Requirements
Increased VE Requirements
Decreased VE RequirementsDecreased VE Requirements
Recommended