Pulmonary Rehabilitation : pratical aspects

Beirut

April 2008 Dr karen Hardy

Pulmonary rehabilitration: pratical aspects

Définition Indications/exclusions Clinical and functional assessment Pulmonary rehabilitation : practical aspect results Clinical case

Pulmonary rehabilitation

Définition : 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 activites. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functianal statues, increase participation, reduce health costs…Rehabilitation include patient assessment, exercise training, education and psychosocial support.

American Thoracic Society and the European Respiratory Society.Am J Respir Crit Care Med 2006

Pulmonary rehabilitation

Indication : WHO ? Essentially COPD patients (44 millions all

over the world) other : cystic fibrosis , bronchectiasis,

Asthma, preparation for surgical treatments, interstitial diseases…

Pulmonary rehabilitation

Indications : When ? Patient with dyspnea, exercice intolerance,

reduced of the health related quality of life (Critères SPLF 2005)

Stable patient or acute exacerbation period (Man BMJ 2004 )

Smoker or not smoker (Lacasse J Cardiopulm rehab 2002;22:148-53)

Before or after surgery Patient motivated +++

Pulmonary rehabilitation

Indication : Where ? In hospital Out patient Home care setting Physical therapist practice

Pulmonary rehabilitation

Exclusions Unstable cardiac disease. Orthopedic or neurologic problems reducing

mobility. Psychiatric unstable disease

(ATS/ERS statement on pulmonary rehabilitation AJRCCM 2006;173 : 1390)

Pulmonary rehabilitation

Evaluation (recommandations SPLF2005; Troosters AJRCCM 2005)

Blood measures and functionnal exercice capacity 6-minute walk test, or shuttle test, or endurance Shuttle Walk test Cardiopulmonary exercise testing Body mass index Inspiratory and expiratory pression measurement Evaluation of muscle strenght Health-related quality of life Breath questionnaire score (Borg)

B

Pulmonary rehabilitation

Short term results Increase exercise capacity Increase Quality of life

Reduce health care cost : (Griffith 2001, Chest 2007; 131)

Pulmonary rehabilitation

Long term results Insuffisance evidence to determine if PR

improves survival in COPD (chest 2007; 131)

Ways to maintain the benefits?

Clinical case

Medical history Surgical : shinebon fracture (2003) respiratory : COPD with emphysem

Way of life Smoker : 10 à 20 cigarettes per day, Fagerström 7/10, HAD :A =5/21 et D=2/21, 25 py, Alcool : weaning since 13 years Work : : works in « France Télécom », with a computer.

Clinical case Story of the disease Since an exacerbation of COPD 6 month ago, the patient discribes more dyspnea and a decreased exercise capacity with a deacreased quality of life

Clinical examination Saturation 94% , RR 18/min, blood pressure and temperature : normals Thoracic distension , decrease of the breath sound Body height: 170cm, weight 55kg Physical examination : normal

Treatment Bronchodilatators

Clinical case

Biology : hb15.8g/dl, hématocrite 47.7%, protidémie 66g/l, Biologic criteria of denutrition., CRP normal. Blood gases : pH = 7.43, PO2=72, PCO2=45, bicar 30, sat 95%. ECG = normal

With this informations, does this

patient need rehabilition?

Clinical case

INDICATION Dicrease quality of life, increase dyspnea Motivated patient Smoker :(Lacasse J Cardiopulm rehab 2002;22:148-53)

Personnal expérience at Aincourt : 62 COPD patients in rehabilitation, 50% smokers the beginning. 64.5% stops, 100% reduces. The increase of exercise was the same in the 2 groups but the quality of life was higher in the smoker group)

Which examinations would you

do for this patient?

Functionnal exercice capacity

6-minute walk test

Cardiopulmonary exercise testing

Where do you do the rehabilitation?

What do you propose to the patient ?

Help for smoking cessation Individual program of exercice training Physical exercise teacher Education Personnal nutritionnal intervention :

nutritional supplementation Psychosocial support

How to do?

PRESCRIPTION

Training intensity at 60% of the peak exercise = 125/MIN, Cardiac rate max=145/MIN,

Minimal SATURATION =90% 30 MINUTES MINIMUM, >20 Sessions (3 per week)

Lower extremity exercise training Endurance training Long exercice training At the Cardiac rate of the borg score of 4 to 6 for

dyspnea Or > 60% maximal work rate SPLF 2005 Clark Eur Respir J 1996;9:2590 High level intensity : 80% of the VO2max Casaburi Am J Respir Crit Care Med 1997;155;1541 Interval training or SWEET: Alternance 1 minute high intensity and 4 minutes at low

intensity Gimenez Eur J Applic phys 1982

Strenght training during = 45 minutes X3 per week