Exercise Prescription for the Pulmonary Patient

1. Chuck Kitchen, MA, FAACVPR Chuck.kitchen@gmail.com Exercise Prescription for the Pulmonary Patient

2. PULMONARY DISEASES OBSTRUCTIVE DISEASES • COPD-Chronic airway obstruction • Emphysema-Hyperinflation of the lungs, can’t get bad air out • Chronic Bronchitis-Chronic sputum production and coughing • Asthma-increased airway reactivity leading to narrowing of airways

3. COVERAGE FOR PULMONARY REHAB • PR only covered for Moderate, Severe, Very Severe COPD • GOLD classification

4. COVERAGE FOR PULMONARY REHAB

5. Appropriate Diagnoses with ICD-9 and ICD-10 Codes for Respiratory Services • Chronic lower respiratory diseases ICD-10: J40-J47 • Obstructive Lung Disease: • Persistent asthma: 493 • Bronchitis: 491 • Bronchiectasis: 494 • COPD: 496 • Cystic fibrosis: 277.03 • Bronchiolitis obliterans: 491.8 • Emphysema: 492 AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th ed. 2010, Champaign, IL: Human Kinetics Publishers.

6. Appropriate Diagnoses with ICD-9 and ICD-10 Codes for Respiratory Services • Restrictive Lung Diseases: • Interstitial diseases: 518.89 (J84.1-9) • Idiopathic interstitial fibrosis: 516.31 (J84.10-J84.111-117) • Other interstitial pulmonary disease with fibrosis: J84.17 • Occupational or environmental lung disease: 518.89(Z57.31) • Sarcoidosis: 517.8 (Lung involvement) (D86.0, 86.2) • Chest wall diseases: • Kyphoscoliosis: 737.3 (M41.8) • Ankylosing spondylitis: 720.0 (M45.3-45.5) AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th ed. 2010, Champaign, IL: Human Kinetics Publishers.

7. Appropriate Diagnoses with ICD-9 and ICD-10 Codes for Respiratory Services • Restrictive Lung Diseases, Continued: • Neuromuscular diseases: • Parkinson’s: 332 (G20) • Postpolio syndrome: 138 (G14) • Amyotrophic lateral sclerosis: 335.2 (G12.21) • Diaphragmatic dysfunction: 518.89 (J98.6) • Multiple sclerosis: 340 (G35) • Post-tuberculosis syndrome: 518.89 (A-15) AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th ed. 2010, Champaign, IL: Human Kinetics Publishers.

8. Appropriate Diagnoses with ICD-9 and ICD-10 Codes for Respiratory Services • Obesity-related Respiratory Disorders: • Obesity hypoventilation syndrome: 278.03 • Obstructive sleep apnea: 327.23 • Other Lung Disorders: • Lung cancer: 162 • Pulmonary hypertension: 416-417.8 ( • Post-lung transplant: V42.6 AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th ed. 2010, Champaign, IL: Human Kinetics Publishers.

9. CMS AND BILLING FOR PR SERVICES • Pulmonary Rehabilitation must be the ONLY service billed using G0424 • Sessions limited to a maximum of two 1-hour sessions per day for up to 36 sessions • Contractors may approve up to an additional 36 sessions when medically necessary. • Providing access of up to 72 sessions of PR, when appropriate • Does not specify a duration by which sessions must be completed; allowing the maximum allowable number of 72 over a longer period of time 42.CFR 410.47

10. PR CODING REQUIREMENTS • G0424: Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session • Revenue Code: 0948 • Session duration: • One session = > 31 minutes • Two sessions = > 91 minutes, with the first session = 60 minutes and second session = 31 minutes • Do NOT bill any other codes for the COPD patient

11. RESTRICTIVE DISEASES • Interstitial Lung Diseases • Environmental-asbestos, dust, coal, etc • Drugs or chemotherapy • Collagen diseases (scleroderma, lupus, etc) • Pulmonary fibrosis • Vascular Lung Diseases • Pulmonary Hypertension

12. ACSM GUIDELINES • 3-5 days per week • Walking (preferred) and cycle • 20-60 min • RPE 5-6 (Moderate) Or 7-8 (Vigorous) for Mild COPD • RPE 3-5 for Moderate to Severe COPD • No upper extremity recommended • Does not use GOLD criteria • Strength Training-2-4 sets, 2-3 days/week

13. RPE 10 POINT SCALE 0 Nothing at all 0.5 Very, Very Light 1 Very Light 2 Fairly Light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard 8 9 10 Very, Very Hard (Maximal)

14. AACVPR GUIDELINES • 3-5 days per week • Walking, cycle, arm ergometry, warm-up and cool down • 20-90 minutes per session • Intensity to achieve patient goals • Upper extremity exercise with lower extremity (arm ergometer) • Strength Training-Hand weights, free weights, machine weights

15. ATS GUIDELINES • 3 days per week • Cycling or walking • > 3o min • RPE 4-6 or predetermined MET level • Arm ergometer, free weights, elastic bands • Strength training-2-4 sets 6-12 reps

16. EXERCISE PRESCRIPTION • 6 Min Walk Test-Widely used tool to determine exercise prescription • Determine initial exercise intensity

17. EXERCISE PRESCRIPTION F.I.T.T PRINCIPLE • Frequency • Intensity • Time • Type

18. EXERCISE PRESCRIPTION FREQUENCY • 3 to 5 times per week

19. EXERCISE PRESCRIPTION INTENSITY • 4-6 Borg Dyspnea scale • 12-14 RPE scale

20. EXERCISE PRESCRIPTION INTENSITY DYSPNEA SCALE (Modified Borg) 0 None 5 Severe 0.5 Very, Very slight 6 1 Very slight 7 Very Severe 2 Slight 8 3 Moderate 9 Very, Very Severe 4 Somewhat severe 10 Maximum

21. 6 7 very, very light 8 9 very light 10 11 light 12 13 somewhat hard 14 15 hard 16 17 very hard 18 19 very, very hard 20 EXERCISE PRESCRIPTION INTENSITY RPE SCALE

22. EXERCISE PRESCRIPTION TIME • 20 to 6o minutes • Can use interval training especially for beginners or low level patients • Total exercise time is most important

23. EXERCISE PRESCRIPTION TYPE • Continuous Aerobic • High Intensity Interval Training not found to have same benefits as with Cardiac Population (CHF, etc) • Possibly due to Dyspnea • Low to moderate intensity interval training can be used • Resistance Training

24. STRENGTH TRAINING • No data for “optimal” resistance training program • Important to help maintain muscle mass (muscle wasting) • 1-3 sets • 8-12 repetitions • 2-3 days per week

25. SPECIAL CONSIDERATIONS • Exercise capacity often limited by dyspnea, not MET level or RPE, etc • SaO2 Monitoring • Supplemental O2 to maintain 88%-90% • Generally, cycle or other non weight bearing equipment has higher O2 sats • Consider continuous exercise on cycle, recumbent stepper, etc. Interval on TM

26. SPECIAL CONSIDERATIONS • Take bronchodilators prior to exercise

27. RESTRICTIVE DISEASES • Short term benefits from PR • Smaller improvements and shorter lasting • Typically more dyspnea than obstructive disease • Generally more reliant on supplemental O2

28. PULMONARY HYPERTENSION • Careful to maintain O2 sats above 88%-90% • Monitor BP and HR • Consider telemetry monitoring • Exercise Intensity should be light to moderate ONLY • Monitor for lightheadedness, chest pain, etc

29. INSPIRATORY MUSCLE TRAINERS

30. INSPIRATORY MUSCLE TRAINING • AACVPR and ACCP do not recognize IMT as part of Pulmonary Rehab • Devices used to impose resistance or load • Patients increase inspiratory muscle strength • Significant decreases in dyspnea • Increased walking distance • However, no increase in peak power • Increased quality of life measures

31. Exercise Prescription is an Art!! Every patient is different EXERCISE PRESCRIPTION

32. REFERENCES • American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign, IL; Human Kinetics, 2010. • Garvey C, Fullwood MD, Rigler J. Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Lung Disease. JCRP 2013; 33: 314-322 • Johnson-Warrington V, Harrison S, Mitchell K, et al. Exercise Capacity and Physical Activity in Patients With COPD and Healthy Subjects Classified as Medical Research Council Dyspnea Scale Grade 2. JCRP 2014; 34(2): 150-154

33. REFERENCES • Ryerson CJ, Cayou C, Toop F, et al. Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study. Respir Med 2014; 108(1): 203-210 • Spruit MA, Singh SJ, Garvey C, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. Am J Respir Crit Care Med 2013; 188(8): e13-e64