Pulmonary Rehabilitation

Susan Scherer, PT, PhDRegis UniversityDPT 732Spring 2009

Pulmonary Rehabilitation

The American Thoracic Society /European Respiratory Society (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, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease.

Pulmonary Rehabilitation

Symptoms correlate better with functional status than does FEV1 or other measures of pulmonary function (AACVPR)

Symptoms, disability, and handicap dictate the need for pulmonary rehabilitation, not the degree of physiologic impairment

Criteria for Referral to Pulm Rehab FEV less than or equal to 65% of predicted value FVC less than or equal to 65% of predicted value Diffusing capacity for carbon monoxide adjusted for

hemoglobin less than or equal to 65% of predicted Resting hypoxemia (SpO2 less than or equal to 90%) Exercise testing demonstrating hypoxemia (SpO2 less

than or equal to 90%) or ventilatory limit (VE/MVV more than or equal to 0.8) or a rising Vd/Vt

Selection of Patients: Indications COPD Restrictive lung disease Neuromuscular disease resulting in decreased

ventilation Pre and post transplant Respiratory disease resulting in:

Anxiety with daily activities Breathlessness with activities Limitation in social, leisure, work or ADLs Loss of independence

Exclusion of Patients

Conditions that would interfere with Patient participation (cognition) Risk during exercise training

Pulmonary hypertension Unstable angina

Core Components of Pulm Rehab Patient Assessment of current functional status Exercise training and other therapeutic exercise (aerobic, strength and

flexibility training) Education and skills training (such as breathing retraining) Secretion clearance techniques for Prevention and management of

exacerbations and pulmonary infections Oxygen systems, proper use, safety and portability Nutritional assessment and intervention if necessary Psychosocial assessment, support, panic control, and professional

intervention if necessary Smoking cessation if currently smoking Medication use, management and education Implementation of a home treatment program follow-up

Demonstrated Outcomes

Reduced respiratory symptoms (dyspnea, fatigue) Increased exercise performance Increased knowledge about pulmonary disease and self-

efficacy in its management Enhanced ability to perform activities of daily living Improved health-related quality of life Improved psychosocial symptoms (reversal of anxiety

and depressive symptoms) Reduced exacerbations and use of medical resources Return to work or leisure activities

Qualified Programs American Association of Cardiovascular and Pulmonary

Rehabilitation (AACVPR) instituted program certification in 1998 to recognize programs that were meeting the published Guidelines for Pulmonary and Cardiac Rehabilitation

Annual staff competency skills review Emergency equipment and supplies Written policies and procedures Regular staff meetings Physician referral process Informed consent form Exercise prescription Preparation for possible medical emergencies Emergency equipment availability Record of untoward events Outcomes assessment/program evaluation Risk stratification Individualized care plan Educational sessions Feedback to physician

Components of Pulmonary Rehabilitation Exercise Training

Aerobic Upper extremity endurance Lower extremity endurance Strength Respiratory muscle

Education Disease management (meds, oxygen) Breathing training Smoking cessation Stress management

Psychological and Social intervention Support group

Outcome Assessment

Benefits of Pulmonary Rehabilitation Impairments-generally not reversed with

medication or pulmonary rehab Disability-pulmonary rehab improves function

Increase in exercise performed Decrease in dyspnea for given level of exercise

American Thoracic Society Guidelines Am J Respir Crit Care Med Vol 159: pp 1666-1682, 1999.

Benefits of Pulmonary Rehabilitation :Maximal Exercise Capacity Positive effect size for exercise – important

because COPD progressively downhill Subjects: FEV1 35-45% of predicted Maximal treadmill work (+33%) after 8 weeks Maximal cycle ergometry (+11%)after 12

weeks home rehab

Troosters, 2000

Benefits of Pulmonary Rehabilitation :Steady State Exercise Endurance Stationary cycle time (at 60% of maximal

power) improved by 5 min over control (+38%)

Treadmill time + 10 min (85% over baseline) 6 minute walk distance

Clinically significant difference 54 m RCT- + 113 m at 6 weeks

Improved daily function and community walking ability

Benefits of Pulmonary Rehabilitation :Dyspnea Reduction Exercise training has effects on more

parameters than dyspnea Benefit to dyspnea greater than medication or

oxygen therapy Decreased dyspnea with daily activities Transitional Dyspnea Index (TDI)

Clinically significant difference: 2.3 units Decreased VAS during max exercise

75—50%

Benefits of Pulmonary Rehabilitation :Health –related Quality of Life Improved Chronic Respiratory Disease

Questionnaire Health status Dyspnea Emotional function

Benefits of Pulmonary Rehabilitation :Mortality & Morbidity % alive in 6 years, not statistically significant Decreased hospital days (2 for pulm rehab vs

6 for controls) Study completed before managed care

Recommendations for Rehabilitation Exercise training muscles of ambulation is recommended as mandatory

component for patients with COPD 1A Lower extremity exercise at higher intensity produces greater

physiologic benefits than lower intensity in patients with COPD 1B Both high and low intensity exercise provide clinical benefits 1A Addition of a strength training component in creases muscle strength

and mass 1A Unsupported endurance training of the UE is beneficial 1A Inspiratory muscle training is not supported by literature 1B Supplemental oxygen should be used in exercise training in patients

with exercise-induced hypoxemia 1C Supplemental oxygen during high intensity exercise in patients without

exercise induced hypoxemia may improve endurance 2A

Chest 2007

Initial Assessment

Review disease process & PFTs Educational assessment for knowledge gaps Baseline exercise capacity Respiratory muscle strength Peripheral muscle strength ADLs Health status Anxiety/depression/mood states Nutritional status (low weight associated with

decreased exercise performance & aerobic capcity

Exercise Training Parameters Frequency: 2-5 times/week Intensity: Aim for general training parameters

> 60% max VO2 Does ventilatory limitation allow patients to train at levels

that will provide physiologic adaptations? Time: Unrealistic to expect 20-30 minutes originally

Few minutes at maximal performed at intervals Interval training (high and low)

Type: Specificity of training – walking vs. cycle

Aerobic Exercise Training

Intensity : 60% of maximal and above

anaerobic threshold As high as 75-85% of peak VO2

HR response is variable Can be used to measure cardiac

adaptation to exercise Dyspnea ratings during exercise

are better indicators of training Peripheral adaptations occur in

exercising muscle Reduced ventilation & lactate

levels at identical work rates indicates training effect

Extremity Endurance Exercise training Upper extremity

Arm ergometer Dowel or weights

unsupported UE above shoulder level

Trains accessory and UE muscles for endurance

Lower extremity Higher intensity work (60-

80% of max workload) increases endurance time more than lower intensity

Strength Training

Peripheral muscle weakness contributes to decreased physical performance

Training 50-85% of 1RM Exercise capacity did not change Improved peripheral muscle function Improved QOL

Respiratory muscle training Minimal load is 30% of PI max

Pulmonary Rehabilitation -Education

Breathing Retraining Individual assessment recommended Coordinating breathing with activity

Energy conservation Proper use of medications Oxygen use Individual or classes

Psychosocial and Behavioral Intervention Anxiety Depression Decreased self-efficacy

Stress management Muscle relaxation Group therapy Support groups

Typical Outcomes

Exercise ability Incremental or submaximal exercise test Walking test (6 minute)

General health status SF-36

Respiratory specific health status Chronic Respiratory Disease Questionnaire CRDQ

Respiratory specific functional status Pulmonary Functional Status Scale PFSS

Exertional dyspnea VAS, Borg, TDI

Typical Outcomes

Exercise ability Incremental or submaximal exercise test Walking test (6 minute)

General health status SF-36

Respiratory specific health status Chronic Respiratory Disease Questionnaire CRDQ

Respiratory specific functional status Pulmonary Functional Status Scale PFSS

Exertional dyspnea VAS, Borg, TDI

Implications for practice

The results of this meta-analysis strongly support respiratory rehabilitation including at least four weeks of exercise training as part of the spectrum of management for patients with COPD. We found clinically and statistically significant improvements in dyspnea, fatigue and mastery.

When compared with the treatment effect of other important modalities of care for patients with COPD such as bronchodilators or oral theophylline (McKay 1993; Jaeschke 1994), rehabilitation resulted in greater improvements in important domains of health-related quality of life and functional exercise capacity.

Clinical practice guidelines must however consider that respiratory rehabilitation is often unavailable. For instance, in Canada, a recent national survey indicated that less than 2% of the population with COPD per annum has access to such program (Brooks 1999).

We hope that the results of this meta-analysis will encourage the implementation of new programs

Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH, Goldstein RS, White J.Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Database of

Systematic Reviews: Reviews 2001