PULMONARY

REHABILITATION

Anna Sárközi MD.

Dept. of Pulmonology

University of Debrecen 05.04.2013

•1

DEFINITION

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

it is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs by stabilizing or reversing systemic manifestations of the disease

Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.

•2

WHY IS IT IMPORTANT ??

The total number of case of COPD in

the world approxi. 280 million persons

6th cause of death worldwide in 1990

by 2002 the ranking had risen to 5th

by 2030 COPD would become the 3-4th

cause of death worldwide (WHO)

Prevalence and morbidity data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced

•3

Age-adjusted death rates for COPD by country and by sex, ages 35 to 74 years adapted from World Health Statistics Annual, WHO

Hurd S Chest 2000;117:1S-4S ©2000 by American College of Chest Physicians •4

MORTALITY TRENDS

NHLBI/WHO 2002

Percent change in age-adjusted death rates; proportion of 1965 rate in the USA

•0

•0.5

•1.0

•1.5

•2.0

•2.5

•3.0

Coronary

heart

disease

Stroke Other CVD COPD All other

causes

1965–1998 1965–1998 1965–1998 1965–1998 1965–1998

– 59% – 64% – 35% + 163% – 7%

•5

WHEN TO START ??

•6

AIMS

•7

PRINCIPAL GOALS OF PULMONARY

REHABILITATION

to reduce the patient symptoms

increase participation in physical and social activities

to decrease disability

to improve the overall quality of life (QOL)

retain the achieved results by the optimal medication in

the treatment

to reduce the numbers of exacerbations, the numbers of

emergency health cares, health care costs and

numbers of hospitalization

stabilizing or reversing systemic manifestations of

disease •8

CONSEQUENCES OF RESPIRATORY DISEASE

Comorbidity Clinical manifestations

peripherial muscle

dysfunction

steroid myopathy, malnutrition, reduced muscle

mass, hypoxemia, electrolyte and acid-base

differences, deconditioning

respiratory muscle

dysfunction

mechanical consequences of hyperinflation,

diaphragm fatigue, malnutrition, hypoxemia, acid-

base and electrolyte disorders

nutritional abnormalities obesity, cachexia, decreased lean fat free body

mass

cardiac impairment deconditioning, cor pulmonale

sceletal disease osteoporosis, kypho-scoliosis

sensory deficit medication side effects (steroids, diuretics,

antibiotics)

psycho-social problems anxiety, depression, panic, addiction, loss of

cognitive function, sleep disturbance, sexual

dysfunction •9

SETTING FOR PULMONARY REHABILITATION

choice varies depending on

distance to program

patient preference

physical, functional, psychosocial status of patient

Outpatient

Inpatient intensive ward

pulmonary ward

rehabilitation ward

Home

Community Based

•10

HOSPITAL WARD

HOSPITAL BASED PROGRAM

monitor the patient over 24h

comorbid conditions

before-after a chest surgery

psychosocial problems

travelling difficulties

after intensive ward attendance, after

permanent automatic respiration

•11

INTERMITTENT POSITIVE

PRESSURE BREATHING

Active training

Mucus management

Recruitment of atelectasis

Special techniques

Photo from Prof. Dr. Pénzes István

•12

OUTPATIENTS

living active life

are employed

mild or middling serious disease

•13

CHOOSE THE RIGHT PATIENT

complain of dyspnea

non-smoking or smoking cessation program

involved

exercise intolerance

adequately motivated

accept the guideline

•14

PATIENTS SELECTION

obstructive diseases : COPD, bronchiectasis, persistent

asthma, bronchiolitis obliterans, cystic fibrosis

restrictive

interstitial diseases

chest wall neuromuscular (for example paralysis of n.phrenicus)

other diseases : lung cancer, pre-post surgery on thorax or abdomen, obesity-related respiratory disease, before – after lung transplantation

Pulmonary Rehabilitation; Guidelines To Success

John E. Hodgkin,MD; Bartolome Celli, MD; GerilynConners, RRT2009

•15

EMPHYSEMA

•16

CHEST X-RAY WITH EMPHYSEMA

•17

CONTRAINDICATION OF PR

Absolute:

inflammation

acidosis

have bloody sputum

acut pulmonary embolia

acut pneumothorax

intolerantia of dyspnea

don´t compensated cor pulmonale

severe heart failure

severe musculo-sceletal disease •18

CONTRAINDICATION OF PR

Relative:

dementia

do not feel like it

drugs are not normally treated with

COPD and asthma bronchiale

•19

ASSESS THE PATIENT'S CONDITION

measurement of lost functions (mild, moderate, serious) :

physical examination

spirometry

x-ray

bloodgas

daily activity record

complications in the patient's medical history, which may occur in the stress test (ischemic heart disease, low oxygen levels, cardiac arrhythmia)

•20

INTERDISCIPLINARY TEAM

pulmonary rehabilitation physicians

specialist nurse and assistant

respiratory, physical and occupational therapists

dieticians

psychologists

social worker

exercise specialist

•21

ESSENTIAL COMPONENTS OF PR

exercise training and chest physiotherapy:

upper and lower endurance training

respiratory muscle training

strength training

psychosocial and behavioral intervention

nutritional advice and intervention

education

smoking cessation program

long-term oxygen therapy

End-life training!! •22

BREATH EXERCISE AND CHEST

PHYSIOTHERAPY

Controlled breathing out exercise

pursed lip respiration

lean forward

diaphragmatic breath

Chest physiotherapy posturnal drainage

to hit and vibrate the chest

flutter and PEEP mask

controlled cough

at forced breathing out

technic

„Breathing is the basic rhythm of life” Hippocrates

•23

PURSED LIP BREATHE

1. breathe in through nose

2. purse the lips as if you are going to whistle

3. breathe out through your pursed lip

4. don’t force the air out

5. breathe out should take

3-4x longer then breathing in

•24

DIAPHRAGMATIC BREATHING

1. place one hand (left) on the upper chest and the other

on your abdomen

2. breathe in slowly but deeply through your

nose keeping the upper chest quiet

3. slowly breathe out through your

pursed lip

4. let your abdomen relax to its original

position

Repeat 10 times, 1-2 times daily

•25

LEAN FORWARD

Lean forward at the waist and keep your back straight

Bending forward can help breathing more easily

Photo from Dr.Somfay A. •26

EXERCISE TRAINING

does not alter underlying respiratory impairment

improve dyspnea

targets endurance training of 60% max for 20-30 minutes,

repeated 2-5 times a week

interval training of 2-3 minutes high intensity with equal periods of

rest or low level exercise is tolerated well

unsupported arm exercise aids ADLs and respiratory accessory

muscle use

respiratory muscle training benefits have not been well

established

•27

LOAD TRAINING FORMS

two kind of load training forms:

endurance load training:

move bigger set of muscle with average intensity:

bicycle ergometer, runner

strengh generate training:

less muscle for a short period

of time with very intensive:

limb motions done with dumbbells

•28

ENDURANCE LOAD TRAINING

The training of the lower limbs:

runner, bicycle ergometer, stairs, in the

hallway, outdoors

over 60% of the max. capacity

30-45 min.

3-5 times a week

Training of upper limbs

•29

STRENGH GENERATIVE TRAINING

With 80% of the once liftable max. weight

8 repetitions

3 rounds

3 times a week

For 6-8 weeks

•30

EDUCATION

medication therapies

types of medication, action, adverse effects,

dose and proper us of inhaled medications

instructions in inhaler technique

appropriate use of oxygen

smoking cessation

therapeutic recreation

nutrition

psychosocial

•31

HOW TO USE THE

OXYGEN THERAPY?

•32

NUTRITIONAL COUNSELLING

both overweight and underweight can be a problem

25% of patients with moderate to severe COPD show a reduction in BMI which is an independent risk factor for mortality in COPD

reasons for difficulty eating should be explored: poor dentition, dyspnoea whilst eating

advise frequent small meals

•33

DIET

Loss of weight, cachexia causes weakness of muscle

Causes:

during meal the respiration changes, reduces arterial oxygensaturation

a full stomach reduces respiratory capacity, increases the dyspnoe

anxiety, depression reduces appetite

increased basic energy consuption

•34

PSYCHOSOCIAL INTERVENTION

Anxiety, depression, difficulties coping with chronic

disease

Aided by regular patient education session or

support groups

Instruction in progressive muscle relaxation, stress

reduction, panic control

•35

BENEFITS

improved exercise capacity

improved muscle strength

reduced dyspnoea

improved health-related QOL

duration of benefit

exercise benefit 12-18 mths

QoL benefit 24 mths

•36

WHAT THE PATIENTS SAY ABOUT PR

„I’m able to walk for 300-400 maters without stopping. I hadn’t been able to do for several years.”

Male age 69

„Being able to see and talk to other patients” Male age 72

„Before I didn’t do anything I just sat down, now I feel I really want to do the exercises. It has given me a new lease of life. Now I have more confidence going out, I go out more often to the market and shops.”

Female age 70

•37

REFERENCES

ATS/ERS statement on pulmonary rehabilitation (2006). American Journal of Respiratory and Critical Care Medicine, 173,1390-1413.

Bernard et al. (1998). Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 158(2), 629-634.

BTS statement (2001). British Thoracic Society standards of care subcommittee on pulmonary rehabilitation. Thorax, 56, 827-834.

Foglio et al. (1999). Long term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction. European Respiratory Journal, 13(1), 125-32.

Griffiths et al. (2001). Cost-effectiveness of an outpatient mulit-disciplinary pulmonary rehabilitation programme. Thorax, 56(10), 779-784.

Guell et al. (2000). Long term effects of outpatient rehabilitation of COPD: A randomised trial. Chest, 117(4), 976-983.

•38

THANKS FOR YOUR ATTENTION

AND PARTICIPATION

•39